Atrial fibrillation: acute: esmolol and verapamil lowered ventricular rate.

Clinical bottom line (level 1b-)

  1. Patients with acute atrial fibrillation who received esmolol or verapamil had a fall in ventricular rate (on average 40 beats per minute).
  2. There was no clear difference in fall in ventricular rate between the two drugs.
  3. In patients with new onset AF or flutter, esmolol was more likely to cause conversion to sinus rhythm (NNT = 3 at 30 minutes) .
Platia et al: American Journal of Cardiology 1989; 63: 925-929
Expires November 2004

The study

Unblinded ?concealed randomised trial with intention-to-treat
Setting: four acute hospitals, USA

45 patients (aged range 31 to 78 years; mean 63, 69% male) atrial fibrillation or flutter with a ventricular rate >120 beats per minute

Excluded if
  • pregnant
  • uncontrolled heart failure
  • sick sinus syndrome without a pacemaker
  • history of intolerance to beta-blockers, calcium channel blockers
  • acute MI within 3 days
  • severely impaired renal or hepatic function
  • other supraventricular tachycardia
  • digitalis toxicity
  • new-onset systolic pressure < 100 mmHg
  • antiarrhythmic agent taken within 2 half-lives blood


    • Note:
  • Patients were stratified for length of AF (> or < 48 hours).


    • Control Group: (n = 24, 24 analysed): verapamil 5-10 mg iv over 2 minutes repeated if necessary
    Experimental Group: (n = 21, 21 analysed): esmolol infusions initially at 2 mg/min increasing to 16 mg /min if required with bolus injections of 10 mg over 30 seconds increasing to 20 mg if required

    100% followed for 30 minutes

    The evidence

    patients with new onset AF or flutter (control n=17; exp n=14)
    Outcome Time to outcome CEREERRRR
    (95% CI)    		ARR
    (95% CI)    		NNT
    (95% CI)
    no sinus rhythm 30 minutes 15
    (88.2%)    		 7
    (50.0%)    		 43%
    (2% to 67%)    		 38.2%
    (7.89% to 68.6%)    		 3
    (1 to 13)

    reduction in heart rate
    Outcome Control Group
    (SD)    		 Experimental Group
    (SD)    		 Mean Difference
    (95% CI)
    before and after esmolol 139
    (18.0)     		100
    (14.0)     		-39.0
    (-49.1 to -28.9)
    before and after verapamil 142
    (20.0)     		98.0
    (15.0)     		-44.0
    (54.3 to -33.7)

    esmolol vs verapamil
    Outcome Control Group
    (SD)    		 Experimental Group
    (SD)    		 Mean Difference
    (95% CI)
    difference in heart rate at 30 minutes 98.0
    (15.0)     		100
    (14.0)     		2.00
    (-6.76 to 10.8)

    Citation

    1. Platia EV, Michelson EL, Porterfield JK, et al: Esmolol versus verapamil in the acute treatment of atrial fibrillation or atrial flutter. American Journal of Cardiology 1989; 63: 925-929
    Contributor: Chris Ball and Clare Wotton, November 2000
    Reviewer:

    Clinical Question.
    Patient acute AF
    Intervention or Exposure esmolol
    Comparison verapamil
    Outcome ventricular rate, conversion to sinus rhythm