Sandbox/Rate Control Strategy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Mugilan Poongkunran M.B.B.S [2]

Rate Control Strategy

Shown below is an algorithm depicting the management of ventricular rate in patients with atrial fibrillation based on the 2014 ACCF/AHA/HRS Guideline for the Management of Patients With Atrial Fibrillation.

Abbreviations: AF: Atrial fibrillation; COPD: Chronic obstructive pulmonary disease; CVD: Cardiovascular disease; EF: Ejection fraction; HF: Heart failure; HFpEF: Heart failure with preserved ejection fraction; HFrEF: Heart failure with reduced ejection fraction; HR: Heart rate; LV: Left ventricle

Stable AF patients requiring heart rate control therapy

Heart rate control goal: ❑ Resting HR <110 bpm in asymptomatic and EF > 40% patients ❑ Resting HR <80 bpm in symptomatic and EF < 40% patients

Does the patient have any evidence of an accessory pathway (pre-excitation syndrome)?

Yes

No

COPD

HFrEF or LV dysfunction

Hypertension or HFpEF or No CVD

❑ Nondihydropyridine calcium channel blockers: Most preferred OR ❑ Beta blockers: Cardioselective ❑ Oral vs IV according to the clinical urgency

❑ Beta blockers: After stabilization in patients with decompensated HF OR ❑ Digoxin ❑ Oral vs IV according to the clinical urgency

❑ Beta blockers OR ❑ Nondihydropyridine calcium channel blockers ❑ Oral vs IV according to the clinical urgency

❑ Procainamide OR ❑ Ibutilide ❑ Oral vs IV according to the clinical urgency

❑ Amiodarone ❑ Oral vs IV according to the clinical urgency

Consider catheter ablation if the accessory pathway has a short refractory period that allows rapid antegrade conduction

Rate Control Drugs & Dosages

Shown below is a table summarizing the list of recommended agents for control of heart rate and their dosages.

Heart Rate Control in Acute Setting Drug Loading dose Maintenance dose Heart rate control in patients without accessory pathway ▸ Esmolol (class I, level of evidence C) ▸ 500 mcg/kg IV over 1 min ▸ 60 to 200 mcg/kg/min IV ▸ Propanolol (class I, level of evidence C) ▸ 0.15 mg/kg IV ▸ NA ▸ Metoprolol (class I, level of evidence C) ▸ 2.5 to 5 mg IV bolus over 2 min; up to 3 doses ▸ NA ▸ Diltiazem (class I, level of evidence B) ▸ 0.25 mg/kg IV over 2 min ▸ 5 to 15 mg/h IV ▸ Verapamil (class I, level of evidence B) ▸ 0.075 to 0.15 mg/kg IV over 2 min ▸ NA Heart rate control in patients with accessory pathway ▸ Amiodarone (class IIa, level of evidence C) ▸ 150 mg over 10 min ▸ 0.5 to 1 mg/min IV Heart Rate Control in patients with heart failure and without accessory pathway ▸ Digoxin (class I, level of evidence B) ▸ 0.25 mg IV each 2 h, up to 1.5 mg ▸ 0.125 to 0.375 mg daily IV or orally ▸ Amiodarone (class IIa, level of evidence C) ▸ 150 mg over 10 min ▸ 0.5 to 1 mg/min IV Heart Rate Control in Non Acute Setting and Long Term Maintenance Heart rate control ▸ Metoprolol (class I, level of evidence C) ▸ 25 to 100 mg twice a day, orally ▸ 25 to 100 mg twice a day, orally ▸ Propanolol (class I, level of evidence C) ▸ 80 to 240 mg daily in divided doses, orally ▸ 80 to 240 mg daily in divided doses, orally ▸ Verapamil (class I, level of evidence B) ▸ 120 to 360 mg daily in divided doses, orally ▸ 120 to 360 mg daily in divided doses, orally ▸ Diltiazem (class I, level of evidence B) ▸ 120 to 360 mg daily in divided doses, orally ▸ 120 to 360 mg daily in divided doses, orally Heart Rate Control in patients with heart failure and without accessory pathway ▸ Digoxin (class I, level of evidence B) ▸ 0.5 mg by mouth daily ▸ 0.125 to 0.375 mg daily, orally ▸ Amiodarone (class IIb, level of evidence C) ▸ 800 mg daily for 1 week, orally 600 mg daily for 1 week, orally 400 mg daily for 4 to 6 week, orally ▸ 200 mg daily, orally

References

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