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Safety and Efficacy of Prehospital Diltiazem for Atrial Fibrillation with Rapid Ventricular Response

  • Alexa Rodriguez (a1) (a2), Christopher L. Hunter (a1) (a2), Caitlin Premuroso (a1), Salvatore Silvestri (a1) (a2), Amanda Stone (a1), Stacie Miller (a1), Christian Zuver (a1) (a2) and Linda Papa (a1)...



Atrial fibrillation (AFIB) with rapid ventricular response (RVR) is a common tachydysrhythmia encountered by Emergency Medical Services (EMS). Current guidelines suggest rate control in stable, symptomatic patients.


Little is known about the safety or efficacy of rate-controlling medications given by prehospital providers. This study assessed a protocol for prehospital administration of diltiazem in the setting of AFIB with RVR for provider protocol compliance, patient clinical improvement, and associated adverse events.


This was a retrospective, cohort study of patients who were administered diltiazem by providers in the Orange County EMS System (Florida USA) over a two-year period. The protocol directed a 0.25mg/kg dose of diltiazem (maximum of 20mg) for stable, symptomatic patients in AFIB with RVR at a rate of >150 beats per minute (bpm) with a narrow complex. Data collected included patient characteristics, vital signs, electrocardiogram (ECG) rhythm before and after diltiazem, and need for rescue or additional medications. Adverse events were defined as systolic blood pressure <90mmHg or administration of intravenous fluid after diltiazem administration. Clinical improvement was defined as a heart rate decreased by 20% or less than 100bmp. Original prehospital ECG rhythm interpretations were compared to physician interpretations performed retrospectively.


Over the study period, 197 patients received diltiazem, with 131 adhering to the protocol. The initial rhythm was AFIB with RVR in 93% of the patients (five percent atrial flutter, two percent supraventricular tachycardia, and one percent sinus tachycardia). The agreement between prehospital and physician rhythm interpretation was 92%, with a Kappa value of 0.454 (P <.001). Overall, there were 22 (11%) adverse events, and 112 (57%) patients showed clinical improvement. When diltiazem was given outside of the existing protocol, the patients had higher rates of adverse events (18% versus eight percent; P = .033). Patients who received diltiazem in adherence with protocols were more likely to show clinical improvement (63% versus 46%; P = .031).


This study suggests that prehospital diltiazem administration for AFIB with RVR is safe and effective when strict protocols are followed.

Rodriguez A, Hunter CL, Premuroso C, Silvestri S, Stone A, Miller S, Zuver C, Papa L. Safety and efficacy of prehospital diltiazem for atrial fibrillation with rapid ventricular response. Prehosp Disaster Med. 2019;34(3):297–302.


Corresponding author

Correspondence: Alexa Rodriguez, MD Associate Medical Director Orange County EMS System 2002-A E Michigan Street Orlando, Florida 32806 USA E-mail:


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1. January, CT, Wann, LS, Alpert, JS, et al. 2014 AHAH/ACC/HRS guideline for management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2014;64(21):e176.
2. Mozaffarian, D, Benjamin, EJ, Go, AS, et al. Heart disease and stroke statistics – 2015 update: a report from the American Heart Association. Circulation. 2015;131(4): e29322.
3. Balderson, J, Aurora, T, Zhang, R, Kontos, M, Gertz, Z. Diltiazem versus esmolol for acute rate control in the emergency department. Am J Emerg Med. 2017;35(11):17591783.
4. Fromm, C, Suau, SJ, Cohen, V, et al. Diltiazem vs. metoprolol in the management of atrial fibrillation or flutter with rapid ventricular rate in the emergency department. J Emerg Med. 2015;49(2):175182.10.1016/j.jemermed.2015.01.014
5. Karth, DG, Geppert, A, Neunteufi, T, et al. Amiodarone versus diltiazem for rate control in critically ill patients with atrial tachyarrhythmias. Crit Care Med. 2001;29(6):11491153.10.1097/00003246-200106000-00011
6. Siu, CW, Lau, CP, Lee, WL, Lam, KF, Tse, HF. Intravenous diltiazem is superior to intravenous amiodarone or digoxin for achieving ventricular rate control in patients with acute uncomplicated atrial fibrillation. Crit Care Med. 2009;37(7):21742179.10.1097/CCM.0b013e3181a02f56
7. Hirschy, R, Ackerbauer, K, Peksa, GD, O’Donnell, P, DeMott, JM. 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(1):8084.
8. Schreck, DM, Rivera, AR, Tricarico, VJ. Emergency management of atrial fibrillation and flutter: intravenous diltiazem versus intravenous digoxin. Ann Emerg Med. 1997;29(1):135140.10.1016/S0196-0644(97)70319-6
9. Wang, HE, O’Connor, RE, Megarel, RE, et al. The use of diltiazem for treating rapid atrial fibrillation in out-of-hospital setting. Ann Emerg Med. 2001;37(1):3845.10.1067/mem.2001.111518
10. Luk, JH, Walsh, B, Yasbin, P. Safety and efficacy of prehospital diltiazem. West J Emerg Med. 2013;14(3):296300.10.5811/westjem.2011.8.6692
11. Lim, SH, Anantharaman, V, Teo, WS, Chan, YH. Slow infusion of calcium channel blockers compared with intravenous adenosine in the emergency treatment of supraventricular tachycardia. Resuscitation. 2009;80(5):523528.10.1016/j.resuscitation.2009.01.017
12. Jacob, AS, Nielsen, DH, Gianelly, RE. Fatal ventricular fibrillation following verapamil in Wolff-Parkinson-White syndrome with atrial fibrillation. Ann Emerg Med. 1985;14(2):159160.10.1016/S0196-0644(85)81080-5



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