Rate control treatment with calcium channel blockers and beta blockers for patients with atrial fibrillation: a systematic review and meta-analysis

Abstract Background and aims Controlling heart rate is a key objective in atrial fibrillation (AF) management, commonly achieved with beta blockers or non-dihydropyridine calcium channel blockers, both class I guideline recommendations. However, their long-term effectiveness has rarely been compared. This review aimed to critically evaluate all available evidence comparing these drug classes in AF treatment. Methods We systematically searched MEDLINE, Embase, Web of Science, and Cochrane Central for original studies published up to March 1st, 2025. Eligible studies included AF patients, compared calcium channel blockers and beta blockers, and reported heart rate or other clinically relevant outcomes. The primary outcome was 24-hour heart rate on Holter monitoring. Meta-analyses were performed where data were sufficiently homogeneous. Results Of 1906 identified records, 25 met inclusion criteria. Five studies reported 24-hour mean heart rate, showing no difference between drug classes (mean difference: 3.6 bpm, 95% CI: -2.9 to 10.1, P = 0.274). Eight studies reported maximum exercise heart rate, which was significantly higher with calcium channel blockers than with beta blockers (mean difference: 10.5 bpm, 95% CI: 3.3 to 17.7, P = 0.043). Other outcomes were too heterogeneous for meta-analysis, though three studies reported increased peak oxygen uptake with calcium channel blockers. Conclusion Calcium channel blockers and beta blockers provide comparable control of mean heart rate in AF. However, patients on calcium channel blockers have a higher maximum heart rate during exercise. In our qualitative synthesis, some studies reported higher peak oxygen uptake calcium channel blocker treated patients, these results should be seen as hypothesis generating.