Intravenous diltiazem versus metoprolol for atrial fibrillation with rapid ventricular rate: A meta-analysis

Am J Emerg Med. 2022 Jan;51:248-256. doi: 10.1016/j.ajem.2021.08.082. Epub 2021 Nov 6.


Background: Intravenous diltiazem and metoprolol are both commonly used to treat atrial fibrillation (AF) with rapid ventricular rate (RVR) in the emergency department (ED), but the advantages and disadvantages of these drugs cannot be verified. This meta-analysis aimed to assess the efficacy and safety of intravenous diltiazem versus metoprolol for AF with RVR.

Method: We systematically searched PubMed, Web of Science, Embase, Cochrane library, the China National Knowledge Infrastructure (CNKI), Wanfang, China Biology Medicine disc (CBM) and the WeiPu (VIP). Meta-analysis was performed using weighted mean difference (WMD), relative risk (RR) and 95% confidence interval (CI). Statistical analysis was performed using Review Manager 5.4.1.

Results: Seventeen studies involving 1214 patients in nine randomized controlled trials (RCTs) and eight cohort studies were included in meta-analysis, including 643 patients in the intravenous diltiazem group and 571 patients group in the intravenous metoprolol. The results of the meta-analysis showed that compared with intravenous metoprolol, intravenous diltiazem was found higher efficacy (RR =1.11; 95% CI = 1.06 to 1.16, p < 0.00001), shorter average onset time (RR = -1.13; 95% CI = -1.97 to -0.28, p = 0.009), lower ventricular rate (RR = -9.48; 95% CI = -12.13 to -6.82, p<0.00001), less impact on systolic blood pressure (WMD = 3.76; 95% CI: 0.20 to 7.33, P = 0.04), and no significant difference in adverse events (RR = 0.80, 95% CI = 0.55 to 1.14, P = 0.22) and diastolic blood pressure (WMD = -1.20; 95% CI: -3.43 to 1.04, P = 0.29) was found between intravenous diltiazem and metoprolol.

Conclusion: Intravenous diltiazem has higher efficacy, shorter average onset time, lower ventricular rate, less impact on blood pressure, and with no increase in adverse events compared to intravenous metoprolol.

Keywords: Atrial fibrillation; Diltiazem; Metoprolol; Rapid ventricular rate.

Publication types

  • Meta-Analysis
  • Systematic Review

MeSH terms

  • Administration, Intravenous
  • Atrial Fibrillation / drug therapy*
  • Blood Pressure / drug effects
  • Diltiazem / administration & dosage
  • Diltiazem / therapeutic use*
  • Heart Rate / drug effects*
  • Humans
  • Metoprolol / administration & dosage
  • Metoprolol / therapeutic use*
  • Randomized Controlled Trials as Topic


  • Diltiazem
  • Metoprolol