Metoprolol vs diltiazem for atrial fibrillation with rapid ventricular rate: Systematic review and meta-analysis of adverse events

Metoprolol vs diltiazem for atrial fibrillation with rapid ventricular rate: Systematic review and meta-analysis of adverse events https://doi.org/10.1016/j.ajem.2024.12.070  Abstract Background Intravenous (IV) diltiazem and metoprolol are commonly used to achieve rate control for atrial fibrillation with rapid ventricular rate (Afib with RVR), and are both recommended as first-line by current guidelines. While prior studies investigated the efficacy of these medications, there is little evidence available regarding the risk of adverse events (AEs) with their use.  Methods We identified randomized controlled trials (RCT) and observational studies reporting rates of adverse events following administration of Intravenous diltiazem and metoprolol for atrial fibrillation with rapid ventricular rate by searching PubMed, SCOPUS, EMBASE, and Cochrane Library. Our primary outcome was the incidence of adverse events and specifically hypotension and bradycardia, which were examined individually as secondary outcomes. We performed random-effects meta-analysis to identify rates of each adverse events. We used moderator analysis and meta-regressions to evaluate risk factors. We used the Cochrane Risk-of-Bias 2 tool and the Newcastle-Ottawa Scale to assess study quality.  Results We reviewed 13 studies and included 1660 patients, 888 (53 %) treated with metoprolol and 772 (47 %) with diltiazem. Metoprolol was associated with a 26 % lower risk of adverse event (total incidence 10 %) compared to diltiazem (total incidence 19 %), (RR 0.74, 95 % CI 0.56–0.98, p = 0.034) with a prediction interval of 0.50–1.10. Patients with higher initial heart rates faced higher rates of adverse events (Correlation Coefficient 0.11, 95 % CI 0.03–0.19, p = 0.006). There was no difference with respect to rates of bradycardia (RR 0.44, 95 % CI 0.15–1.30, p = 0.14) or hypotension (RR 0.80, 95 % CI 0.61–1.04, p = 0.10).  Conclusion Atrial fibrillation with rapid ventricular rate treated with metoprolol had lower rates of adverse event (bradycardia and/or hypotension) compared to those treated with diltiazem. We found no difference in rates of hypotension or bradycardia when individually assessed. Existing data are limited by small sample sizes, variability in dosing, and limited representation of important patient subgroups. Disclaimer: Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of any scientific information shared by the HCP on the ­­­STAR UPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on this website.