Diltiazem versus metoprolol for rate control in atrial fibrillation with rapid ventricular response in the emergency department

Am J Health Syst Pharm. 2016 Dec 15;73(24):2068-2076. doi: 10.2146/ajhp160126.


Purpose: The impact of patient-specific factors on the choice of β-blocker versus calcium channel blocker therapy for rate control in emergency department (ED) patients treated for atrial fibrillation (AF) was investigated.

Methods: A retrospective cohort study was conducted to evaluate the influence of demographics, prior medication use, hemodynamic and clinical characteristics, and other variables on selection of first-line therapy for AF among patients admitted to the ED of an academic medical center over a 22-month period (October 2012-July 2014) who received i.v. treatment with either the β-blocker metoprolol (n = 45) or the calcium channel blocker diltiazem (n = 55) for rate control.

Results: Significant predictors of the selection of metoprolol versus diltiazem included a past history of AF (odds ratio [OR], 8.3; 95% confidence interval [CI], 1.396-72.713; p = 0.032) or diabetes mellitus (OR, 7.2; 95% CI, 1.208-58.490; p = 0.042) and being prescribed a β-blocker prior to presentation (OR, 27.8; 95% CI, 4.704-272.894; p = 0.001); a history of calcium channel blocker use prior to ED presentation was a negative predictor of β-blocker use for initial rate control (OR, 0.1; 95% CI, 0.005-0.265; p = 0.002). No differences in the effectiveness or safety of diltiazem and metoprolol were identified. Indicators of hemodynamic and clinical response to ED management were not predictive of discharge medication selection.

Conclusion: The drug class used for rate control prior to ED admission was the most significant predictor of medication selection for rate control in the ED setting.

Keywords: atrial fibrillation; calcium channel blocker; emergency department; rate control; β-blocker.

Publication types

  • Comparative Study

MeSH terms

  • Administration, Intravenous
  • Adrenergic beta-Antagonists / administration & dosage*
  • Aged
  • Atrial Fibrillation / diagnosis
  • Atrial Fibrillation / drug therapy*
  • Atrial Fibrillation / physiopathology
  • Calcium Channel Blockers / administration & dosage*
  • Cohort Studies
  • Diltiazem / administration & dosage*
  • Emergency Service, Hospital*
  • Female
  • Humans
  • Male
  • Metoprolol / administration & dosage*
  • Middle Aged
  • Retrospective Studies
  • Time Factors


  • Adrenergic beta-Antagonists
  • Calcium Channel Blockers
  • Diltiazem
  • Metoprolol