Atrial fibrillation with rapid ventricular response (AF with RVR) is one of the most common dysrhythmias encountered in the emergency department and often requires prompt rate control. Diltiazem remains a go-to agent due to its rapid onset, AV nodal selectivity, and reliable heart rate reduction. However, hypotension occurs in up to 13% of patients, occasionally symptomatic in 4% of patients, and particularly concerning in those with limited reserve (Ellenbogen 1995). 
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