Treatment with beta-blockers vs amiodarone, calcium channel blockers, or digoxin was associated with improved heart control at 1, but not 6 hours in patients with sepsis and atrial fibrillation (AF), according to a study published in Chest.

In this study, the data of 666 patients (mean age, 72 years) with sepsis and AF with rapid ventricular response (RVR), or a heart rate >110 beats per minute (BPM), identified within the eICU Collaborative Research Database were examined. This database includes the data of patients admitted to 208 US hospitals participating in Philips telehealth system.

In this cohort, patients were treated with the beta-blocker metoprolol (n=67), the calcium channel blocker esmolol diltiazem (n=225), verapamil amiodarone (n=337), or digoxin (n=37). The mean heart rate at time of AF medication administration was 128 BPM. A total of 208 patients (31.2%) died during the index hospitalization.

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After adjusting for competing risks for death, and the use of additional AF, rate, or rhythm control medications, the adjusted hazard ratios (HRs) for heart rate <110 BMP within 1 hour of treatment were the following: 0.50 (95% CI, 0.34-0.74; P <.001) for amiodarone vs beta blocker; 0.37 (95% CI, 0.18-0.77; P =.007) for digoxin vs beta blocker; and 0.75 (95% CI, 0.51-1.11; P =.15) for calcium channel blocker vs beta blocker.

The adjusted HRs for heart rate <110 BPM, 6 hours after treatment were: 0.67 (95% CI, 0.47-0.97; P =.03) for amiodarone vs beta blocker; 0.60 (95% CI, 0.36-1.004; P =.052) for digoxin vs beta blocker; and 1.03 (95% CI 0.71-1.49; P =.88) for calcium channel blocker vs beta blocker.

In secondary effectiveness outcomes analyses (n=636), larger reductions in heart rate at 1 hour were observed in patients who received a beta-blocker. In the first 1 hour after treatment, the mean adjusted heart rate were: 115 BPM (95% CI, 112-118) for patients treated with a beta-blocker vs 122 BPM (95% CI, 122-123) for patients treated with amiodarone (P <.001); 122 BPM (95% CI, 120-124) for patients treated with a calcium channel blocker (P <.001); and 124 BPM (95% CI, 119-129) for patients treated with digoxin (P =.002).

Heart rate control at 6 hours was comparable for all treatments.

The adjusted odds of hypotension were lower in patients treated with digoxin vs beta-blockers (adjusted odds ratio, 0.20; 95% CI, 0.07-0.63; P =.006).

A limitation of this study was the higher baseline rates of mechanical ventilation and vasopressor requirements in the amiodarone group.

 “[C]linicians aiming to reduce heart rate rapidly among patients with sepsis and AF with RVR who do not require cardioversion should consider beta-blockers as first-line therapy,” concluded the study authors.

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.


Bosch NA, Rucci JM, Massaro JM, et al. Comparative effectiveness of heart rate control medications for the treatment of sepsis-associated atrial fibrillation. Published online October 24, 2020. Chest. doi: 10.1016/j.chest.2020.10.049