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<p>Atrial fibrillation with rapid ventricular rate is common and difficult to manage. The evidence for the effectiveness of intravenous rate-controlling drugs is limited. In this study, MIMIC-IV was used to simulate the target trial, comparing “diltiazem initiation” with “metoprolol initiation”: patients were enrolled with the first administration as T0, excluding those with concurrent initial medications, missing baseline heart rate, non-rapid ventricular rate, and insufficient observation window; missing data were imputed, and propensity score weighting was used to balance covariates. The primary outcome was achievement of heart rate &lt; 110 beats/min within the first hour after T0; the secondary outcomes were recorded additional AF-related medication within 6&#xa0;h after T0, in-hospital death, and ICU stay days. A total of 1492 cases were included (321 cases of diltiazem and 1171 cases of metoprolol), and the absolute SMD after weighting was close to 0. Diltiazem initiation was associated with a lower probability of achieving the primary outcome (OR = 0.67, 95% CI 0.51–0.88) and a higher probability of requiring additional medication within 6&#xa0;h (OR = 2. 63, 95% CI 1. 98–3. 49); there was no significant difference in in-hospital death (OR = 0. 88, 95% CI 0. 66–1. 17) and ICU stay days (MD = −0. 41 days, 95% CI −1. 42 to 0. 61). The subgroup directions were consistent, and the interaction P for mechanical ventilation was 0. 057. Overall, metoprolol initiation was associated with a higher probability of early rate control and a lower probability of short-term additional AF-related medication in the overlap population, although these findings should be interpreted as hypothesis-generating because of residual confounding and limitations of structured electronic health-record data.</p>

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Diltiazem versus metoprolol for atrial fibrillation with rapid ventricular rate in ICU patients using target trial emulation

  • 期刊论文

  • 出版模式：

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  • 发表日期：

    2026年7月17日

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  • Jinhao Deng,
  • Lin Chen,
  • Wei Zhang,
  • Xiaolin Zhang,
  • Xiaoqian Lu,
  • Zhigang Wang,
  • Jun Lyu

摘要

Atrial fibrillation with rapid ventricular rate is common and difficult to manage. The evidence for the effectiveness of intravenous rate-controlling drugs is limited. In this study, MIMIC-IV was used to simulate the target trial, comparing “diltiazem initiation” with “metoprolol initiation”: patients were enrolled with the first administration as T0, excluding those with concurrent initial medications, missing baseline heart rate, non-rapid ventricular rate, and insufficient observation window; missing data were imputed, and propensity score weighting was used to balance covariates. The primary outcome was achievement of heart rate < 110 beats/min within the first hour after T0; the secondary outcomes were recorded additional AF-related medication within 6 h after T0, in-hospital death, and ICU stay days. A total of 1492 cases were included (321 cases of diltiazem and 1171 cases of metoprolol), and the absolute SMD after weighting was close to 0. Diltiazem initiation was associated with a lower probability of achieving the primary outcome (OR = 0.67, 95% CI 0.51–0.88) and a higher probability of requiring additional medication within 6 h (OR = 2. 63, 95% CI 1. 98–3. 49); there was no significant difference in in-hospital death (OR = 0. 88, 95% CI 0. 66–1. 17) and ICU stay days (MD = −0. 41 days, 95% CI −1. 42 to 0. 61). The subgroup directions were consistent, and the interaction P for mechanical ventilation was 0. 057. Overall, metoprolol initiation was associated with a higher probability of early rate control and a lower probability of short-term additional AF-related medication in the overlap population, although these findings should be interpreted as hypothesis-generating because of residual confounding and limitations of structured electronic health-record data.