Can diltiazem (Dilzem) be discontinued in a patient with rate‑controlled atrial fibrillation?

Discontinuation of Diltiazem in Rate-Controlled Atrial Fibrillation

Diltiazem should generally not be discontinued in patients with rate-controlled atrial fibrillation, as rate control therapy is a continuous treatment strategy—not a temporary bridge—and withdrawal typically results in return to rapid ventricular rates within hours to days. 1, 2

Guideline Framework for Rate Control as Ongoing Therapy

• The 2024 European Society of Cardiology guidelines explicitly recommend rate control therapy as either an adjunct to rhythm control strategies or as a sole treatment strategy to control heart rate and reduce symptoms in atrial fibrillation. 3

• Beta-blockers, diltiazem, verapamil, or digoxin are designated as first-choice drugs for patients with AF and LVEF >40% to control heart rate and reduce symptoms, with no provision for discontinuation once rate control is achieved. 3

• Rate control is a Class I recommendation as a continuous management approach, not a temporary intervention that can be stopped after achieving target heart rate. 1

Evidence Against Discontinuation

• Research demonstrates that when diltiazem infusion is discontinued after achieving rate control, patients require transition to oral diltiazem to maintain control—not complete cessation of therapy. 2

• In a study evaluating transition from IV to oral diltiazem, withdrawal of therapy resulted in loss of rate control, with only 77% maintaining control when transitioned to oral formulation (not discontinued entirely). 2

• Older research from 1987 showed that on withdrawal of diltiazem, ventricular response returned to baseline values, confirming that the drug provides symptomatic control rather than disease modification. 4

Clinical Scenarios Where Discontinuation May Be Considered

The only appropriate scenarios for diltiazem discontinuation are:

• Development of contraindications: New diagnosis of heart failure with LVEF ≤40%, hemodynamic instability, or symptomatic bradycardia/hypotension. 1, 5

• Successful rhythm control: If the patient undergoes cardioversion or catheter ablation and maintains stable sinus rhythm, rate control agents may be tapered under close monitoring. 3

• Transition to alternative rate control agent: Switching to a beta-blocker for additional mortality benefit in patients who develop heart failure, or to digoxin/amiodarone if LVEF declines below 40%. 1, 5

Practical Algorithm for Decision-Making

Step 1: Assess current cardiac function

• If LVEF remains >40% and patient is asymptomatic with controlled rate → continue diltiazem indefinitely. 3, 1
• If LVEF has declined to ≤40% → transition to digoxin or amiodarone, do not simply discontinue. 1, 5

Step 2: Evaluate rhythm status

• If patient remains in persistent/permanent AF → rate control must continue. 3
• If patient has converted to stable sinus rhythm (confirmed over weeks to months) → consider cautious taper with close monitoring. 3

Step 3: Assess symptom control

• If patient is asymptomatic with heart rate <110 bpm at rest → maintain current therapy. 1
• If patient develops symptoms despite rate control → consider rhythm control strategy, not discontinuation of rate control. 3

Common Pitfalls to Avoid

• Do not discontinue diltiazem simply because the heart rate is controlled—this confuses the therapeutic effect with disease resolution. 4, 2

• Do not assume rate control can be stopped after a period of stability—atrial fibrillation is a chronic condition requiring ongoing management unless rhythm control is achieved. 3

• Remember that anticoagulation decisions remain unchanged regardless of rate control status, as diltiazem does not restore sinus rhythm or reduce stroke risk. 1

• If considering discontinuation due to side effects, transition to an alternative rate control agent rather than leaving the patient uncontrolled. 1, 5

Monitoring After Any Medication Change

• Target lenient rate control initially (<110 bpm at rest), with stricter control (<80 bpm) reserved for symptomatic patients. 1

• If diltiazem must be discontinued due to contraindications, ensure alternative rate control is established before complete withdrawal. 5

• Combination therapy with digoxin and diltiazem produces synergistic effects and may allow lower doses of each agent, potentially improving tolerability without discontinuation. 1, 6