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PACU Literature Review #10: Acute Management of Atrial Fibrillation in Congestive Heart Failure with Reduced Ejection Fraction in the Emergency Department

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Hasbrouck M, Nguyen TT. Acute management of atrial fibrillation in congestive heart failure with reduced ejection fraction in the emergency department. Am J Emerg Med. 2022 Apr 6;58:39-42.
PMID: 35623182


  • To compare the incidence of adverse effects in the HFrEF patient population whose AF with RVR was treated with IV diltiazem or metoprolol in the ED.


  • Single-center, the retrospective review included patients ≥18 years old with HFrEF who presented in AF with RVR and received IV diltiazem or metoprolol in the ED.

Study Intervention & Comparison

  • IV diltiazem or metoprolol


  • Primary Outcome
    • Overall adverse effects for diltiazem and metoprolol were similar (32% vs. 21%, P = 0.217).
  • Secondary Outcomes
    • Significantly higher incidence of worsening heart failure symptoms within the diltiazem group (33% vs 15%, P = 0.019)
    • Rate control failure at 60 min did not differ significantly between diltiazem and metoprolol (51% vs 62%, P = 0.277).


  • In HFrEF patients with AF, there was no difference in total adverse events in patients treated with IV diltiazem compared to metoprolol. However, the diltiazem group had a higher incidence of worsening CHF symptoms defined as increased oxygen requirement within four hours or initiation of inotropic support within 48 h.

Additional Readings

  • Jandali M.B.: Safety of intravenous diltiazem in reduced ejection fraction heart failure with rapid atrial fibrillation. Clin Drug Investig 2018; 38: pp. 503-508.
  • Hirschy R., Ackerbauer K.A., Peksa G.D., O’Donnell E.P., DeMott J.M.: Metoprolol vs. diltiazem in the acute management of atrial fibrillation in patients with heart failure with reduced ejection fraction. Am J Emerg Med 2019; 37: pp. 80-84.
  • Demircan C., Cikriklar H.I., Engindeniz Z., et. al.: Comparison of the effectiveness of intravenous diltiazem and metoprolol in the management of rapid ventricular rate in atrial fibrillation. Emerg Med J 2005; 22: pp. 411-414.
  • Kotecha D., Piccini J.P.: Atrial fibrillation in heart failure: what should we do?. Eur Heart J 2015; 36: pp. 3250-3257