Evaluation of metoprolol versus diltiazem for rate control of atrial fibrillation in the emergency department

Am J Emerg Med. 2021 Aug:46:585-590. doi: 10.1016/j.ajem.2020.11.039. Epub 2020 Nov 22.


Objective: The purpose of this study was to compare the effectiveness and safety of the metoprolol and diltiazem administration in the Emergency Department (ED) for rate control of supraventricular tachycardia.

Methods: This was a retrospective cohort study of adult patients who presented to the ED with ventricular rates ≥120 beats per minute (bpm) and who received bolus doses of either intravenous metoprolol or intravenous diltiazem. The primary outcome was achievement of rate control, defined as heart rate < 110 bpm, at two hours after administration of the last bolus dose of metoprolol or diltiazem. Safety outcomes included occurrence of hypotension, defined as systolic blood pressure < 90 mmHg or diastolic blood pressure < 60 mmHg, and bradycardia, defined as heart rate < 60 bpm.

Results: There were 166 patients receiving metoprolol and 183 patients receiving diltiazem included in the study. The primary outcome, rate control at two hours after the last bolus dose of metoprolol or diltiazem was similar between the two groups (45.8% vs 42.6%, p = 0.590, respectively). The percentage of patients achieving rate control was also similar (47.0% vs 41.6%, p = 0.333) at one hour. At 0.5 h HR had a significantly greater numerical (diltiazem: 29.3 ± 23.1 bpm vs metoprolol: 21.8 ± 18.9 bpm, p = 0.012) and percent decrease (21.1% vs 15.94%, p = 0.014) in the diltiazem group compared to metoprolol. There was no significant difference in occurrence of bradycardia in the two groups (diltiazem: 3.83% vs metoprolol: 1.2%, p = 0.179). More patients in the diltiazem group compared to the metoprolol group experienced hypotension (39.3% vs 23.5%, p = 0.002). The difference in systolic hypotension events was not significantly different (9.29% vs 5.42%, p = 0.221), while the difference in diastolic hypotension events was significantly different (37.7% vs 22.3%, p = 0.002).

Conclusion: There was no difference in acute rate control effectiveness two hours after the last bolus dose of diltiazem and metoprolol for supraventricular tachycardias. There was a significantly higher occurrence of hypotension in the diltiazem group which was driven by higher rates of diastolic blood pressures less than 60 mmHg.

Keywords: Atrial fibrillation; Diltiazem; Metoprolol; Rate control; Tachycardia.

MeSH terms

  • Adult
  • Aged
  • Anti-Arrhythmia Agents / pharmacology
  • Anti-Arrhythmia Agents / standards
  • Atrial Fibrillation / drug therapy*
  • Atrial Fibrillation / physiopathology
  • Diltiazem / pharmacology
  • Diltiazem / standards*
  • Emergency Service, Hospital / organization & administration
  • Emergency Service, Hospital / statistics & numerical data
  • Heart Rate / drug effects*
  • Humans
  • Male
  • Metoprolol / pharmacology
  • Metoprolol / standards*
  • Middle Aged
  • Retrospective Studies


  • Anti-Arrhythmia Agents
  • Diltiazem
  • Metoprolol