Intravenous Verapamil for the Management of Atrial Fibrillation: The Gap Between the Guidelines and Clinical Practice

Objective According to the current guidelines, the use of non-dihydropyridine calcium-channel blockers for the rate control of atrial fibrillation (AF) is contraindicated in patients with heart failure (HF), especially in those with a reduced ejection fraction (EF). However, there is little data supporting this recommendation. This study aimed to investigate the use of intravenous verapamil in patients with AF. Methods We retrospectively studied 223 consecutive patients with AF treated with intravenous verapamil. We evaluated the clinical data of these patients, including any adverse events that occurred within 7 days. Results The median age of the patients was 75.9 (67.8-80.7) years. Before administration, 71 patients (31.8%) had HF, 112 patients (62.6%) had a high B-type natriuretic peptide (BNP) level, and 28 patients (13.6%) had a left ventricular (LV) EF less than 50%. The mean administered dose of verapamil was 5.4±1.6 mg. The median heart rate (HR) was significantly reduced after verapamil administration [HR:145 (130-160) bpm to 95 (82-105) bpm, p<0.001]. Twenty-eight patients (12.6%) suffered from hypotension. Two patients had bradyarrhythmias. Within 7 days, cardiovascular death occurred in three patients (1.3%). A multivariate analysis revealed that pre sBP and hemoglobin, but not LVEF or BNP, were independently associated with adverse events. Conclusion The intravenous administration of verapamil appears to be effective and safe for controlling the heart rate in most patients with AF, except in critically ill patients. However, further research is required to assess the safety of verapamil in patients for whom its use is not currently recommended by the clinical guidelines.