Diltiazem vs metoprolol for atrial fibrillation with rapid ventricular response in heart failure with reduced ejection fraction in emergency departments
,
Abstract
Objective: As emergency department (ED) visits for atrial fibrillation (AF) grow, comorbidities lead to challenging treatment scenarios. There are limited data evaluating the safety of diltiazem in the acute management of AF with rapid ventricular rate (RVR) in patients with heart failure with reduced ejection fraction (HFrEF). The objective of this study was to evaluate the safety of diltiazem vs metoprolol in patients presenting to the ED with AF with RVR with HFrEF. Methods: This multicenter, retrospective, cohort study evaluated patients with AF with RVR with HFrEF who received either intravenous (IV) diltiazem or metoprolol in the ED. The primary endpoint was worsening heart failure, defined as an increase in supplemental oxygen requirement, acute kidney injury (AKI), or inotrope administration. Secondary endpoints included bradycardia, systolic blood pressure (SBP) <90 mmHg, or atropine administration. Results: Of the 5,465 patients screened, 62 (1.1%) patients were included for analysis. Forty-nine (79%) patients received IV diltiazem and 13 (21%) received IV metoprolol. The primary endpoint of worsening heart failure occurred in 26.5% in the diltiazem cohort and 15.4% in the metoprolol cohort (P=0.493). There were no differences in increased need for supplemental oxygen, incidence of AKI, or inotropic support. There were no differences in the secondary safety endpoints. Conclusion: For ED management of patients with AF with RVR with HFrEF, treatment with IV diltiazem did not lead to an increase in worsening heart failure compared to IV metoprolol. Future prospective trials are needed to evaluate this treatment approach in this population.
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2. Chiang CE, NaditchBrûlé L, Murin J, Geothals M, Inoue H, O’Neill J, et al. Distribution and risk profile of paroxysmal, persistent, and permanent atrial fibrillation in routine clinical practice. Circulation: Arrhythmia Electrophysiol. 2012;5(4):632-39.
3. Anter E, Jessup M, Callans DJ. Atrial fibrillation and heart failure: treatment considerations for a dual epidemic. Circulation. 2009;119(18):2516-25.
4. January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland Jr JC, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the heart rhythm society. J Am Coll Cardiol. 2014;130(23):2071-104.
5. January CT, Wann LS, Calkins H, Chen LY, Cigarroa JE, Cleveland Jr JC,et al. 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 in collaboration with the society of thoracic surgeons. Circulation. 2019;140(2):e125-e51.
6. Rogenstein C, Kelly AM, Mason S, Schneider S, Lang E, Clement CM, et al. An international view of how recent-onset atrial fibrillation is treated in the emergency department. Acad Emerg Med. 2012;19(11):1255-60.
7. Low RI, Takeda P, Mason DT, DeMaria AN. The effects of calcium channel blocking agents on cardiovascular function. Am J Card. 1982;49(3):547-53.
8. The Danish Study Group. Effect of verapamil on mortality and major events after acute myocardial infarction (The Danish Verapamil Infarction Trial II — DAVIT II). Am J Card. 1990;66(10):779-85.
9. Goldstein RE, Boccuzzi SJ, Cruess D, Nattel S. Diltiazem increases late-onset congestive heart failure in postinfarction patients with early reduction in ejection fraction. The adverse experience committee; and the multicenter diltiazem postinfarction research group. Circulation. 1991;83(1):52-60.
10. Multicenter diltiazem postinfarction trial research group. The effect of diltiazem on mortality and reinfarction after myocardial infarction. N Engl J Med. 1988;319(7)385-92.
11. Ellenbogen KA, Dias VC, Plumb VJ, Heywood JT, Mirvis DM. A placebo-controlled trial of continuous intravenous diltiazem infusion for 24-hour heart rate control during atrial fibrillation and atrial flutter: a multicenter study. J Am Coll Cardiol. 1991;18(4):891-97.
12. Steinberg JS, Katz RJ, Bren GB, Buff LA, Varghese PJ. Efficacy of oral diltiazem to control ventricular response in chronic atrial fibrillation at rest and during exercise. J Am Coll Cardiol. 1987;9(2):405-11.
13. Siu CW, Lau CP, Lee WL, Lam KF, Tse HF. Intravenous diltiazem is superior to intravenous amiodarone or digoxin for achieving ventricular rate control in patients with acute uncomplicated atrial fibrillation. Crit Care Med. 2009;37(7):2174-9.
14. Hirschy RA, Ackerbauer KA, Peksa GD, O’Donnell EP, DeMott JM. 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(1):80-4.
15. Hasbrouck M, Nguyen TT. Acute management of atrial fibrillation in congestive heart failure with reduced ejection fraction in the emergency department. Am J Emerg Med. 2022;58:39-42.
16. Compagner CT, Wysocki CR, Reich EK, Zimmerman LH, Holzhausen JM. Intravenous metoprolol versus diltiazem for atrial fibrillation with concomitant heart failure. Am J Emerg Med. 2022;62:49-54.
17. Kapustova K, Phan B, Allison-Aipa T, Choi M. Acute rate control with metoprolol versus diltiazem in atrial fibrillation with heart failure with reduced ejection fraction. Am J Emerg Med. 2023;67:126-9.
18. Xiao SQ, Ibarra Jr F, Cruz M. Intravenous metoprolol versus diltiazem for rate control in atrial fibrillation. Ann Pharmacother. 2022;56(8):916-21.
19. Niforatos JD, Ehmann MR, Balhara KS, Hinson JS, Ramcharran L, Lobner K, et al.Management of atrial flutter and atrial fibrillation with rapid ventricular response in patients with acute decompensated heart failure: A systematic review. Acad Emerg Med. 2023;30(2):124-32.
20. Olsson T, Terent A, Lind L. Rapid emergency medicine score: a new prognostic tool for in-hospital mortality in nonsurgical emergency department patients. J Intern Med. 2004;255(5):579-87.
21. Kidney disease: improving global outcomes (KDIGO) CKD work group.. KDIGO 2024 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int. 2024;105(4): S117-S314.
22. Felker GM, Lee KL, Bull DA, Redfield MM, Stevenson LW, Goldsmith SR, et al. Diuretic strategies in patients with acute decompensated heart failure. New Engl J Med. 2011;364(9):797-805.
23. Van Gelder IC, Groenveld HF, Crijns HJ, Tuininga YS, Tijssen J, Alings AM, et al. Lenient versus strict rate control in patients with atrial fibrillation. N Engl J Med. 2010;362(15):1363-73.
24. Wyse DG. Therapeutic considerations in applying rate control therapy for atrial fibrillation. J Cardiovasc Pharmacol. 2008;52(1):11-7.
25. Daoud EG, Weiss R, Bahu M, Knight BP, Bogun F, Goyal R, et al. Effect of an irregular ventricular rhythm on cardiac output. Am J Cardiol. 1996;78(12):1433-6.
26. Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomstrom-Lundqvist C, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS) The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2021;42(5):373-498.
27. Butler J, Gheorghiade M, Kelkar A, Fenarow GC, Anker S, Greene SJ, et al. In-hospital worsening heart failure. Eur J Heart Fail. 2015;17(11):1104-13.
2. Chiang CE, NaditchBrûlé L, Murin J, Geothals M, Inoue H, O’Neill J, et al. Distribution and risk profile of paroxysmal, persistent, and permanent atrial fibrillation in routine clinical practice. Circulation: Arrhythmia Electrophysiol. 2012;5(4):632-39.
3. Anter E, Jessup M, Callans DJ. Atrial fibrillation and heart failure: treatment considerations for a dual epidemic. Circulation. 2009;119(18):2516-25.
4. January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland Jr JC, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the heart rhythm society. J Am Coll Cardiol. 2014;130(23):2071-104.
5. January CT, Wann LS, Calkins H, Chen LY, Cigarroa JE, Cleveland Jr JC,et al. 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 in collaboration with the society of thoracic surgeons. Circulation. 2019;140(2):e125-e51.
6. Rogenstein C, Kelly AM, Mason S, Schneider S, Lang E, Clement CM, et al. An international view of how recent-onset atrial fibrillation is treated in the emergency department. Acad Emerg Med. 2012;19(11):1255-60.
7. Low RI, Takeda P, Mason DT, DeMaria AN. The effects of calcium channel blocking agents on cardiovascular function. Am J Card. 1982;49(3):547-53.
8. The Danish Study Group. Effect of verapamil on mortality and major events after acute myocardial infarction (The Danish Verapamil Infarction Trial II — DAVIT II). Am J Card. 1990;66(10):779-85.
9. Goldstein RE, Boccuzzi SJ, Cruess D, Nattel S. Diltiazem increases late-onset congestive heart failure in postinfarction patients with early reduction in ejection fraction. The adverse experience committee; and the multicenter diltiazem postinfarction research group. Circulation. 1991;83(1):52-60.
10. Multicenter diltiazem postinfarction trial research group. The effect of diltiazem on mortality and reinfarction after myocardial infarction. N Engl J Med. 1988;319(7)385-92.
11. Ellenbogen KA, Dias VC, Plumb VJ, Heywood JT, Mirvis DM. A placebo-controlled trial of continuous intravenous diltiazem infusion for 24-hour heart rate control during atrial fibrillation and atrial flutter: a multicenter study. J Am Coll Cardiol. 1991;18(4):891-97.
12. Steinberg JS, Katz RJ, Bren GB, Buff LA, Varghese PJ. Efficacy of oral diltiazem to control ventricular response in chronic atrial fibrillation at rest and during exercise. J Am Coll Cardiol. 1987;9(2):405-11.
13. Siu CW, Lau CP, Lee WL, Lam KF, Tse HF. Intravenous diltiazem is superior to intravenous amiodarone or digoxin for achieving ventricular rate control in patients with acute uncomplicated atrial fibrillation. Crit Care Med. 2009;37(7):2174-9.
14. Hirschy RA, Ackerbauer KA, Peksa GD, O’Donnell EP, DeMott JM. 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(1):80-4.
15. Hasbrouck M, Nguyen TT. Acute management of atrial fibrillation in congestive heart failure with reduced ejection fraction in the emergency department. Am J Emerg Med. 2022;58:39-42.
16. Compagner CT, Wysocki CR, Reich EK, Zimmerman LH, Holzhausen JM. Intravenous metoprolol versus diltiazem for atrial fibrillation with concomitant heart failure. Am J Emerg Med. 2022;62:49-54.
17. Kapustova K, Phan B, Allison-Aipa T, Choi M. Acute rate control with metoprolol versus diltiazem in atrial fibrillation with heart failure with reduced ejection fraction. Am J Emerg Med. 2023;67:126-9.
18. Xiao SQ, Ibarra Jr F, Cruz M. Intravenous metoprolol versus diltiazem for rate control in atrial fibrillation. Ann Pharmacother. 2022;56(8):916-21.
19. Niforatos JD, Ehmann MR, Balhara KS, Hinson JS, Ramcharran L, Lobner K, et al.Management of atrial flutter and atrial fibrillation with rapid ventricular response in patients with acute decompensated heart failure: A systematic review. Acad Emerg Med. 2023;30(2):124-32.
20. Olsson T, Terent A, Lind L. Rapid emergency medicine score: a new prognostic tool for in-hospital mortality in nonsurgical emergency department patients. J Intern Med. 2004;255(5):579-87.
21. Kidney disease: improving global outcomes (KDIGO) CKD work group.. KDIGO 2024 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int. 2024;105(4): S117-S314.
22. Felker GM, Lee KL, Bull DA, Redfield MM, Stevenson LW, Goldsmith SR, et al. Diuretic strategies in patients with acute decompensated heart failure. New Engl J Med. 2011;364(9):797-805.
23. Van Gelder IC, Groenveld HF, Crijns HJ, Tuininga YS, Tijssen J, Alings AM, et al. Lenient versus strict rate control in patients with atrial fibrillation. N Engl J Med. 2010;362(15):1363-73.
24. Wyse DG. Therapeutic considerations in applying rate control therapy for atrial fibrillation. J Cardiovasc Pharmacol. 2008;52(1):11-7.
25. Daoud EG, Weiss R, Bahu M, Knight BP, Bogun F, Goyal R, et al. Effect of an irregular ventricular rhythm on cardiac output. Am J Cardiol. 1996;78(12):1433-6.
26. Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomstrom-Lundqvist C, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS) The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2021;42(5):373-498.
27. Butler J, Gheorghiade M, Kelkar A, Fenarow GC, Anker S, Greene SJ, et al. In-hospital worsening heart failure. Eur J Heart Fail. 2015;17(11):1104-13.
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How to Cite
1.
Joachim A, Mercer K, Gutierrez M, Waxler C, Aradhya S. Diltiazem vs metoprolol for atrial fibrillation with rapid ventricular response in heart failure with reduced ejection fraction in emergency departments. Front Emerg Med. 2025;.
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