Jaya Fnu, Afzal Maria, Anusha Fnu, Kumari Muskan, Kumar Ajay, Saleem Saqib, Kumar Aman, Bhatia Vishal, Islam Rabia, Kumar Manoj, Kumar Rameet, Islam Hamza, Muzammil Muhammad Ali, Kumar Satesh, Khatri Mahima
Department of Medicine, Ziauddin University Hospital, Karachi, Pakistan.
Department of Medicine, Bahria University of Medical and Dental College, Karachi, Pakistan.
J Innov Card Rhythm Manag. 2024 Sep 15;15(9):6022-6036. doi: 10.19102/icrm.2024.15095. eCollection 2024 Sep.
Atrial fibrillation (AF) is the most common cardiac arrhythmia in the United States, affecting 2.7-6.1 million people. AF can cause symptoms, but when it triggers a rapid ventricular response (RVR), most patients suffer from decompensation. Therefore, we performed an umbrella review of systematic reviews and meta-analyses comparing intravenous (IV) metoprolol and diltiazem to identify discrepancies, fill in knowledge gaps, and develop standardized decision-making guidelines for physicians to manage AF with RVR. A comprehensive search was conducted in PubMed, the Cochrane Library, and Scopus to identify studies for this umbrella review. The overall certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation method, while the quality of the included reviews was evaluated using AMSTAR 2, the Cochrane Collaboration tool, and the Newcastle-Ottawa scale. This study comprehensively analyzed four meta-analyses covering 11 randomized controlled trials and 19 observational studies. The analysis showed that IV diltiazem treatment was significantly more successful in rate control for AF with rapid ventricular response (RVR) than IV metoprolol (risk ratio [RR], 1.30; 95% confidence interval [CI], 1.09-1.56; = 0%; = .003). IV diltiazem also led to a significantly greater reduction in ventricular rate (mean difference, -14.55; 95% CI, -16.93 to -12.16; = 72%; < .00001), particularly at 10 min. The analysis also revealed a significantly increased risk of hypotension associated with treatment with IV diltiazem (RR, 1.43; 95% CI, 1.14-1.79; = 0%; = .002). In conclusion, IV diltiazem therapy achieved better rate control and ventricular rate decrease than metoprolol therapy in AF with RVR. Future clinical trials should compare calcium channel blockers and β-blockers for heart rate control efficacy and safety, considering adverse events.
心房颤动（AF）是美国最常见的心律失常，影响着270万至610万人。AF可能会引发症状，但当它引发快速心室反应（RVR）时，大多数患者会出现失代偿。因此，我们对比较静脉注射美托洛尔和地尔硫䓬的系统评价和荟萃分析进行了一项汇总分析，以找出差异、填补知识空白，并为医生制定标准化的决策指南，用于管理伴有RVR的AF。在PubMed、Cochrane图书馆和Scopus中进行了全面检索，以确定用于该汇总分析的研究。使用推荐分级评估、制定和评价方法评估证据的总体确定性，同时使用AMSTAR 2、Cochrane协作工具和纽卡斯尔-渥太华量表评估纳入评价的质量。本研究全面分析了四项荟萃分析，涵盖11项随机对照试验和19项观察性研究。分析表明，对于伴有快速心室反应（RVR）的AF，静脉注射地尔硫䓬在心率控制方面比静脉注射美托洛尔显著更成功（风险比[RR]，1.30；95%置信区间[CI]，1.09 - 1.56；I² = 0%；P = 0.003）。静脉注射地尔硫䓬还导致心室率显著更大幅度的降低（平均差，-14.55；95% CI，-16.93至-12.16；I² = 72%；P < 0.00001），尤其是在10分钟时。分析还显示，与静脉注射地尔硫䓬治疗相关的低血压风险显著增加（RR，1.43；95% CI，1.14 - 1.79；I² = 0%；P = 0.002）。总之，对于伴有RVR的AF，静脉注射地尔硫䓬治疗在心率控制和心室率降低方面比美托洛尔治疗效果更好。未来的临床试验应比较钙通道阻滞剂和β受体阻滞剂在心率控制疗效和安全性方面的差异，并考虑不良事件。
