Efficacy, Safety, and Feasibility of Verapamil in the Management of Atrial Fibrillation in Emergency Services with Limited Resources: A Systematic Review

Introduction: Atrial fibrillation represents one of the most frequent arrhythmias in emergency services, particularly in settings with limited resources where clear protocols and accessible drugs are required. Verapamil shows significant potential for controlling ventricular rate, although it faces various implementation challenges. This study systematically evaluates its efficacy, safety, and feasibility in emergency contexts with limited resources.  Methods: A systematic review was conducted following PRISMA guidelines. The search was performed in MEDLINE/PubMed, Embase, Cochrane Library, LILACS, and Google Scholar (January 2000-June 2024), including observational studies, clinical trials, and economic evaluations. Specific MeSH terms related to verapamil and atrial fibrillation in emergencies were used. Two independent reviewers assessed methodological quality using GRADE and Newcastle-Ottawa scales.  Results: Of 487 articles identified, 42 met inclusion criteria. Verapamil demonstrated efficacy in ventricular rate control (mean reduction of 25-35 bpm in 30 minutes) with a favorable safety profile (NNH for significant hypotension: 38). Structured protocols reduced hospital admissions (18%, p<0.01) and need for cardioversions (22%, p<0.005) without requiring additional personnel. Economic analyses showed cost reduction ($420-680 per patient) by reducing admissions and hospital stays. "Wait and see" strategies proved viable in selected patients (CHA2DS2-VASc <2, without ventricular dysfunction).  Discussion: The findings demonstrate that verapamil, when implemented within structured protocols, represents an effective alternative for ventricular rate control in atrial fibrillation in emergency services. Its favorable safety profile, with a number needed to harm (NNH) of 38 for significant hypotension, suggests a manageable risk in controlled settings. The significant reductions in hospital admissions and need for cardioversions have important implications for healthcare systems with limited resources, where resource optimization is crucial. Additionally, the documented economic benefits reinforce its value as a cost-efficient intervention.  Conclusions: Verapamil constitutes an effective, safe, and cost-efficient option for the management of atrial fibrillation in emergency settings with limited resources when implemented within structured protocols. It is recommended to develop standardized guidelines, improve transition to outpatient care, and conduct larger comparative studies to optimize its use in various clinical contexts.