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Verapamil Vs Diltiazem

verapamil vs diltiazem

Rate Control for Atrial Fibrillation: What Is the Best Drug to Use?

Current guidelines recommend either a beta-blocker or a calcium-channel blocker as first-line rate-control treatment for atrial fibrillation (AF). However, head-to-head trials of the agents in current use are lacking. To compare the effects of four once-daily drug regimens on heart rate and AF-related symptoms in patients with permanent, rapidly conducted AF, investigators in Norway conducted a prospective, randomized, investigator-blind, crossover study. Sixty adults (mean age, 71; 18 women) with permanent AF and without congestive heart failure or ischemic heart disease received, in randomized order, diltiazem, 360 mg; verapamil, 240 mg; metoprolol, 100 mg; and carvedilol, 25 mg. Each drug was given for 3 weeks to ensure steady-state plasma concentration and adequate washout of the prior treatment. Before the first treatment and on the last day of each treatment protocol, 24-hour Holter recordings were obtained, and patients completed questionnaires on symptom frequency and severity.

Contraindications and precautions

In congestive heart failure, patients with reduced ventricular function may not be able to counteract the inotropic and chronotropic effects of diltiazem, the result being an even higher compromise of function.

With SA node or AV conduction disturbances, the use of diltiazem should be avoided in patients with SA or AV nodal abnormalities, because of its negative chronotropic and dromotropic effects.

Low blood pressure patients, with systolic blood pressures below 90 mm Hg, should not be treated with diltiazem.

Diltiazem may paradoxically increase ventricular rate in patients with Wolff-Parkinson-White syndrome because of accessory conduction pathways.

Diltiazem is relatively contraindicated in the presence of sick sinus syndrome, atrioventricular node conduction disturbances, bradycardia, impaired left ventricle function, peripheral artery occlusive disease, and chronic obstructive pulmonary disease.


The diagnosis of atrial fibrillation should be considered in elderly patients who present with complaints of shortness of breath, dizziness, or palpitations. The arrhythmia should also be suspected in patients with acute fatigue or exacerbation of congestive heart failure.

 In some patients, atrial fibrillation may be identified on the basis of an irregularly irregular pulse or an electrocardiogram (ECG) obtained for the evaluation of another condition.

Cardiac conditions commonly associated with the development of atrial fibrillation include rheumatic mitral valve disease, coronary artery disease, congestive heart failure, and hypertension.

Noncardiac conditions that can predispose patients to develop atrial fibrillation include hyperthyroidism, hypoxia, alcohol intoxication, and surgery.

The ECG is the mainstay for diagnosis of atrial fibrillation. An irregularly irregular rhythm, inconsistent R-R interval, and absence of P waves are usually noted on the cardiac monitor or ECG.

Atrial fibrillation waves (f waves), which are small, irregular waves seen as a rapid-cycle baseline fluctuation, indicate rapid atrial activity (usually between 150 and 300 beats per minute) and are the hallmark of the arrhythmia.

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