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Calcium channel blockers for heart rate control in atrial fibrillation complicated by congestive heart failure
1Heart Failure Clinic, Loma Linda University, California, USA.
Insights
Verapamil and diltiazem may help control ventricular rate in atrial fibrillation (AF) with heart failure, but their long-term safety for heart rate control is uncertain. Further research is needed for chronic use in patients with LV systolic dysfunction.
Area of Science:
- Cardiology
- Pharmacology
Background:
- Atrial fibrillation (AF) with left ventricular (LV) systolic dysfunction presents unique challenges for rate control.
- Verapamil and diltiazem are calcium channel blockers used for rate control in AF.
Purpose of the Study:
- To review the safety and efficacy of verapamil and diltiazem for ventricular response in AF among patients with LV systolic dysfunction.
Main Methods:
- A MEDLINE and manual literature search (1984-1993) identified case reports, trials, reviews, and editorials.
- Data extraction focused on hemodynamic effects, ventricular response, clinical parameters, and mortality.
Main Results:
- Limited data exist on verapamil/diltiazem in heart failure; diltiazem shows fewer in vitro negative inotropic effects than verapamil.
- While verapamil may cause transient deterioration, diltiazem appears not to exacerbate heart failure but can cause hypotension.
- Concerns exist regarding diltiazem's potential to increase mortality in chronic AF with heart failure.
Conclusions:
- Calcium channel blockers may aid acute ventricular rate reduction in AF with heart failure.
- The safety of verapamil and diltiazem for chronic heart rate control in this population requires further investigation.
Objectives:
To review the safety and efficacy of verapamil and diltiazem with respect to ventricular response in atrial fibrillation (AF) in the setting of left ventricular (LV) systolic dysfunction.
Data Sources:
Pertinent articles were identified through a MEDLINE search of the English language literature from 1984 to 1993, followed by a manual search of the bibliographies of pertinent articles.
Study Selection:
Studies selected were case reports, controlled trials, review articles and editorials.
Data Extraction:
Effects of verapamil and diltiazem on hemodynamics, ventricular response in AF, clinical parameters and mortality were reviewed.
Data Synthesis:
There are limited data about the effects of verapamil and diltiazem on ventricular function in patients with congestive heart failure. In vitro diltiazem has fewer negative inotropic effects than verapamil. Clinically there are some reports of hemodynamic and clinical deterioration in patients with significant LV dysfunction given verapamil although most patients improve with verapamil. There are more data concerning diltiazem in the setting of AF complicated by congestive heart failure. The drug does not appear to exacerbate heart failure, although hypotension can result. In chronic AF complicated by heart failure, there is concern that diltiazem may increase mortality. Options for therapy are digoxin, beta-blockers and atrioventricular node ablation.
Conclusions:
Calcium channel blockers may have a role in the acute reduction of ventricular response in patients with AF complicated by congestive heart failure; however, their safety in chronic heart rate control remains to be proven.