(976) Metoprolol vs Diltiazem for Acute Atrial Fibrillation With Rapid Ventricular Rate: A Meta-Analysis

Sunday, January 21, 2024

2:30 PM – 3:30 PM MT

Location: Connections Central - RST 15

First Author(s)

TH

Trager Hintze, PharmD

Clinical Assistant Professor
University Health System
College Station, Texas

Co-Author(s)

Nicole M. Acquisto, BCCCP, PharmD

Clinical Research Pharmacist
Strong Memorial Hospital of the University of Rochester
Rochester, NY, United States
JC

Jasmine Carino, NA

Pharmacy Student
Texas A&M School of Pharmacy, United States
HF

Harry Flaster, MD

Emergency Medicine Resident
Johns Hopkins, United States
AS

Arjun Sharma, NA

Medical Student
University of Maryland School of Medicine, United States
KD

Katherine Downton, MSLIS

Librarian
University of Maryland Health Sciences and Human Services Library, United States
mM

madison Moran, NA

Clinical Research Associate
University of Maryland School of Medicine, United States
IY

Isha Yardi, NA

Medical Student
University of Maryland Department of Emergency Medicine, United States
Quincy K. Tran, MD, PhD, FACEP (he/him/his)

Associate Professor
University of Maryland Medical Center
Baltimore, MD

Introduction: AFIB with RVR is a common cardiac arrhythmia in the Emergency Department (ED) and it is most often treated with metoprolol or diltiazem. Both agents have shown efficacy in reducing patients’ heart rate, however, recent literature has favored diltiazem. Overall, evaluations of these agents have focused on efficacy with less emphasis on adverse effects (AE). We performed a systematic review and meta-analysis comparing metoprolol and diltiazem for treatment of acute AFIB with RVR with a focus on AE.

Methods: A comprehensive literature search of PubMed, EMBASE, Scopus and Cochrane since their beginning to May 9, 2023 was performed. Full-text articles comparing metoprolol and diltiazem for acute AFIB with RVR and involving adult patients were included. The primary outcome was cumulative rate of AE (hypotension, bradycardia), as defined by the study authors. Random-effects meta-analysis, and multivariate meta-regressions were performed to identify the risk factors for AE.

Results: We analyzed 13 articles which included 1660 total patients (metoprolol = 888; diltiazem = 772). Overall, mean heart rate was 142 bpm (SD  6) and mean systolic blood pressure before treatment was 133 mmHg (SD  4). Cumulative AE occurred in 10.4% (n=92) and 17.4% (n=134) in the metoprolol and diltiazem groups, respectively. Hypotension occurred more often (metoprolol 10.1% (n=88); diltiazem 15.4% (n=119)) than bradycardia (metoprolol 0.5% (n=4); diltiazem 3.1% (n=24)) when comparing AE individually. Analysis of cumulative AE between diltiazem and metoprolol resulted in a relative risk of 0.77 (95% 0.58-1.04; P=0.08, I2 = 7%). Meta-regression for the rate of cumulative AE showed only higher heart rate was positively proportional to the cumulative AE rates (Correlate coefficient 0.11, 95% CI 0.03 to 0.19, P=0.01).

Conclusions: The cumulative rates of AE were not statistically different between metoprolol and diltiazem. In exploratory meta-regression, an acute AFIB with RVR patient who presents with a higher heart rate has a greater risk for AE. Future prospective studies are warranted to further compare AE profiles of these two medications.