Is Diltiazem on the Beers List and what are the alternatives?

Is Diltiazem ER on the Beers List?

Yes, diltiazem (a nondihydropyridine calcium channel blocker) is on the 2019 AGS Beers Criteria as a medication to avoid in older adults with heart failure with reduced ejection fraction (HFrEF), with a strong recommendation based on moderate quality evidence. 1

Beers Criteria Specifics

• Table 3 of the 2019 AGS Beers Criteria lists diltiazem under "Drug-Disease or Drug-Syndrome Interactions" 1
• Diltiazem should be avoided in older adults with HFrEF due to risk of worsening heart failure 1
• The recommendation is strong, with moderate quality evidence 1
• Diltiazem is NOT on the Beers list for general avoidance in all older adults—only specifically contraindicated in those with systolic heart failure or severe LV dysfunction 1

What Can Replace Diltiazem?

For Rate Control in Atrial Fibrillation:

• Beta-blockers are the preferred first-line alternative in older adults, particularly those with heart failure 1
• Beta-blockers have an excellent safety profile and are effective for rate control 1
• If beta-blockers are contraindicated, digoxin can be considered for rate control in AF with heart failure 1

For Hypertension Management:

The replacement depends on comorbidities:

If the patient has heart failure with reduced ejection fraction:

• ACE inhibitors or ARBs (first-line) 1
• Beta-blockers (evidence-based for HFrEF) 1
• Aldosterone antagonists if severe HF (NYHA class III-IV or LVEF ≤40%) 1
• Thiazide or loop diuretics as needed 1
• Hydralazine/isosorbide dinitrate (particularly in Black patients) 1

If the patient has stable angina WITHOUT heart failure:

• Beta-blockers remain first-line 1
• ACE inhibitors or ARBs can be added 1
• Dihydropyridine calcium channel blockers (like amlodipine or nifedipine) can be added to beta-blockers—these are NOT on the Beers list for HFrEF 1

If the patient has hypertension with high CAD risk but no heart failure:

• ACE inhibitors or ARBs 1
• Thiazide diuretics 1
• Dihydropyridine calcium channel blockers (amlodipine, nifedipine) 1

Critical Pitfalls to Avoid

• Do NOT substitute verapamil for diltiazem in older adults with heart failure—verapamil is also a nondihydropyridine CCB with the same contraindication 1
• Dihydropyridine CCBs (amlodipine, nifedipine) are NOT contraindicated in heart failure and can be safely used, unlike nondihydropyridines 1
• If diltiazem was being used for supraventricular tachycardia (SVT) or AVNRT, catheter ablation is the preferred definitive treatment over chronic medication therapy 1
• Recent evidence shows that even low-dose diltiazem in patients with reduced EF who require hospital admission carries a 17% risk of worsening heart failure within 24 hours 2

When Diltiazem May Still Be Appropriate in Older Adults

Diltiazem remains appropriate in older adults who:

• Have preserved ejection fraction (≥50%) 1
• Have hypertension or angina WITHOUT heart failure 1
• Require treatment for supraventricular arrhythmias and have normal ventricular function 1
• Have stable angina where beta-blockers are contraindicated AND there is no LV dysfunction 1