Atrial fibrillation rate control: Difference between revisions

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{{Atrial fibrillation}}
{{Atrial fibrillation}}
{{CMG}}; {{AE}} {{CZ}}
{{CMG}}; {{AE}} {{CZ}} {{Anahita}} {{SemRikken}}


==Overview==
==Overview==
 
[[heart rate|Rate]] and [[sinus rhythm|rhythm]] control is the first step in [[treatment]] of [[Hemodynamics|hemodynamically stable]] [[patients]] with acute (less than 48 hours) [[atrial fibrillation]]. It is also considered as a first step [[treatment]] for [[patients]] who developed [[atrial fibrillation]] after a [[heart|cardiac]] [[surgery]].[[Atrial fibrillation]] with rapid [[ventricle|ventricular rate]] is a common finding in many hospitalized [[patients]]. The [[ventricle|ventricular]] rate may be increased up to 150-170. It is essential to bring the [[ventricle|ventricular]] rate down to less than 110 because a rapid [[ventricle|ventricular]] response can cause [[Hemodynamic instability|hemodynamic instabilities]] and [[tachycardia]] mediated [[cardiomyopathy|cardiomyopathies]] ([[heart failure]]). [[Atrial fibrillation]] ([[AF]]) can cause disabling and annoying [[symptoms]]. [[Palpitations]], [[Angina pectoris|angina]], [[fatigue|lassitude]] (weariness), and decreased [[Physical exercise|exercise]] tolerance are related to [[rapid heart rate]] and inefficient [[cardiac output]] caused by [[atrial fibrillation]] ([[AF]]). This can significantly increase [[mortality rate|mortality]] and [[morbidity]], which can be prevented by early and adequate [[treatment]] of the [[atrial fibrillation]] ([[AF]]).
[[Atrial fibrillation]] with rapid ventricular rate is a common finding in many hospitalized patients. The ventricular rate may be increased up to 150-170. It is essential to bring the ventricular rate down to less than 110 because a rapid ventricular response can cause hemodynamic instabilities and [[tachycardia]] mediated [[cardiomyopathy|cardiomyopathies]] ([[heart failure]]). AF can cause disabling and annoying symptoms. [[Palpitations]], [[Angina pectoris|angina]], lassitude (weariness), and decreased exercise tolerance are related to [[rapid heart rate]] and inefficient [[cardiac output]] caused by AF. This can significantly increase mortality and morbidity, which can be prevented by early and adequate treatment of the AF.
 
==Rate Control==
==Rate Control==
===Rate Control versus Rhythm Control===
[[heart rate|Rate control]] is the first step should be taken in [[treatment]] of [[patients]] with [[atrial fibrillation]]. Based on NICE guideline the exception of this rule is the following conditions:<ref name="pmid34020968">{{cite journal| author=Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee| title=Atrial fibrillation: diagnosis and management-summary of NICE guidance. | journal=BMJ | year= 2021 | volume= 373 | issue=  | pages= n1150 | pmid=34020968 | doi=10.1136/bmj.n1150 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34020968  }} </ref>
There are two ways to approach symptoms: rate control and rhythm control.
*If [[atrial fibrillation]] is due to a reversible condition
*Rate control treatments seek to reduce the [[heart rate]] to normal while allowing the patient to remain in AF.  A goal of < 110bpm (lenient rate control) is usually targeted, since patients do not seem to do any better with stricter control<ref>Isabelle C. Van Gelder, M.D., Hessel F. Groenveld, M.D., Harry J.G.M. Crijns, M.D., Ype S. Tuininga, M.D., Jan G.P. Tijssen, Ph.D., A. Marco Alings, M.D., Hans L. Hillege, M.D., Johanna A. Bergsma-Kadijk, M.Sc., Jan H. Cornel, M.D., Otto Kamp, M.D., Raymond Tukkie, M.D., Hans A. Bosker, M.D., Dirk J. Van Veldhuisen, M.D., and Maarten P. Van den Berg, M.D., for the RACE II Investigators* Lenient versus Strict Rate Control in Patients with Atrial Fibrillation. NEJM 2010; 362:1363-1373 April 15, 2010DOI: 10.1056/NEJMoa1001337
*When [[heart failure]] due to [[atrial fibrillation]] has developed
</ref>.
*In new onset [[atrial fibrillation]]
*Rhythm control seeks to restore the [[sinus rhythm|normal heart rhythm]], called normal [[sinus rhythm]]. Options for rhythm control include anti-arrhythmic medications (flecainide, amiodarone, sotalol, and others), catheter-based ablation procedures, and surgical ablation procedures.
*In the presence of a [[atrial flutter]] that could be restored to [[sinus rhythm]] with [[ablation]] [[therapy]]
*Rate control with [[anticoagulation]] was found to be non-inferior to rhythm control in terms of mortality outcomes in the AFFIRM Trial.<ref name="pmid12466506">{{cite journal | author=Wyse DG, Waldo AL, DiMarco JP, Domanski MJ, Rosenberg Y, Schron EB, Kellen JC, Greene HL, Mickel MC, Dalquist JE, Corley SD | title=A comparison of rate control and rhythm control in patients with atrial fibrillation | journal=N Engl J Med | year=2002 | pages=1825-33 | volume=347 | issue=23 }} PMID 12466506</ref>
*In conditions that clinical judgment prefer rhythm control
*AFFIRM also showed no reduction in risk of stroke with rhythm control strategy compared to rate control with anticoagulation.<ref name="pmid12466506" />
[[heart rate|Rate control]] could be considered as a first step [[treatment]] for [[patients]] who developed [[atrial fibrillation]] after a [[heart|cardiac]] [[surgery]].<ref name="pmid34020968">{{cite journal| author=Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee| title=Atrial fibrillation: diagnosis and management-summary of NICE guidance. | journal=BMJ | year= 2021 | volume= 373 | issue=  | pages= n1150 | pmid=34020968 | doi=10.1136/bmj.n1150 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34020968  }} </ref>
*Based on this evidence, a rhythm control strategy is no longer pursued in most AF patients, since the anti-arrhythmic drugs can have serious side effects and catheter or surgical ablation procedures have risks as well.
===Pharmacologic Rate Control===
*Rhythm control may be desired when the patient is significantly symptomatic despite rate control, or if the patients cannot tolerate rate control medications.
*The [[ventricle|ventricular rate]] in [[atrial fibrillation]] is a major determinant of [[symptoms]] and [[Hemodynamics|hemodynamic consequences]].<ref name="pmid34020968">{{cite journal| author=Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee| title=Atrial fibrillation: diagnosis and management-summary of NICE guidance. | journal=BMJ | year= 2021 | volume= 373 | issue=  | pages= n1150 | pmid=34020968 | doi=10.1136/bmj.n1150 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34020968  }} </ref>  
*The [[ventricle|ventricular rate]] is usually reduced by using [[Atrioventricular node|atrioventricular nodal]]-blocking agents. First-line [[therapy|therapies]] include a standard [[beta blockers]] (a [[beta blocker]] except [[sotalol]]) and [[Calcium channel blocker|nondihydropyridine calcium-channel blockers]] ([[verapamil]] and [[diltiazem]]).<ref name="pmid34020968">{{cite journal| author=Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee| title=Atrial fibrillation: diagnosis and management-summary of NICE guidance. | journal=BMJ | year= 2021 | volume= 373 | issue=  | pages= n1150 | pmid=34020968 | doi=10.1136/bmj.n1150 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34020968  }} </ref>  
*Specific [[Adverse effect (medicine)|adverse effects]] of each [[medication]] should be taken into consideration when choosing appropriate [[therapy]] for each individual [[patient]].
*If [[monotherapy]] with the aforementioned [[drugs]] are not effective, combination [[therapy]] with 2 of the following should be considered in order to achieve appropriate rate:<ref name="pmid34020968">{{cite journal| author=Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee| title=Atrial fibrillation: diagnosis and management-summary of NICE guidance. | journal=BMJ | year= 2021 | volume= 373 | issue=  | pages= n1150 | pmid=34020968 | doi=10.1136/bmj.n1150 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34020968  }} </ref>
**[[Beta blocker]]
**[[Calcium channel blocker]]
**[[Digoxin]]


===Pharmacologic Rate Control===
====Mechanism of Action====
====Mechanism of Action====
*Rate control is achieved with medications that work by increasing the degree of block at the [[AV node]], effectively decreasing the number of impulses that conduct to the ventricles. This can be accomplished with:
*[[heart rate|Rate]] control is achieved with [[medications]] that work by increasing the degree of the block at the [[atrioventricular node]], effectively decreasing the number of impulses that conduct to the [[ventricles]]. This can be accomplished with:
:*[[Calcium channel blocker]]s ([[diltiazem]] or [[verapamil]]) block the influx of calcium and reduce the upstroke of the action potential.
:*[[Calcium channel blocker]]s ([[diltiazem]] or [[verapamil]]) block the influx of [[calcium]] and reduce the upstroke of the [[action potential]].
:*[[Beta blockers]] (preferably the cardioselective beta blockers such as [[metoprolol]], [[atenolol]], [[bisoprolol]]) slow conduction by decreasing sympathetic tone.
:*[[Beta blockers]] (preferably the [[beta blockers|cardioselective beta blockers]] such as [[metoprolol]], [[atenolol]], [[bisoprolol]]) slow conduction by decreasing [[Sympathetic nervous system|sympathetic tone]].
:*[[Cardiac glycosides]] (i.e. [[digoxin]]) are vagomimetics and slow conduction by increasing parasympathetic effects on the node.
:*[[Cardiac glycosides]] (i.e. [[digoxin]]) are vagomimetics and slow conduction by increasing [[Parasympathetic nervous system|parasympathetic]] effects on the node.
:*[[Amiodarone]] is a class III anti-arrhythmic drug which also has AV node blocking effects.   Amiodarone can be used for rate control when other agents are contraindicated or ineffective. The classic situation where amiodarone would be used is when a patient is hypotensive (often septic), but also in AF with rapid ventricular response. Beta-blockers and calcium channel blockers are not ideal due to negative inotropic effects. Amiodarone has less negative inotropy and is preferred for this situation.
:*[[Amiodarone]] is a [[Antiarrhythmic agent|class III anti-arrhythmic drug]] which also has [[atrioventricular node]] blocking effects. [[Amiodarone]] can be used for [[heart rate|rate]] control when other agents are [[contraindication|contraindicated]] or ineffective. The classic situation where [[amiodarone]] would be used is when a [[patient]] is [[Hypotension|hypotensive]] (often [[Sepsis|septic]]), but also in [[atrial fibrillation]] with rapid [[ventricle|ventricular]] response. [[Beta blockers]] and [[calcium channel blockers]] are not ideal due to negative [[Inotrope|inotropic effects]]. [[Amiodarone]] has less negative [[Inotrope|inotropy]] and is preferred for this situation.


====Beta Blockers====
====Beta Blockers====
*Efficacy: Low
**Sinus rhythm is maintained in <20% of patients
**Symtoms are reduced in >=20%.
=====Acute Beta Blocker Therapy=====
=====Acute Beta Blocker Therapy=====
*Intravenous beta blocker like [[metoprolol]] and [[esmolol]].
*[[Intravenous therapy|Intravenous]] [[beta blocker]] like [[metoprolol]] and [[esmolol]].
*Useful when atrial fibrillation is secondary to high adrenergic tone like in post operative situations.
*Useful when [[atrial fibrillation]] is secondary to high adrenergic tone like in [[operation|post operative]] situations.
=====Metoprolol=====
======Metoprolol======
*Dose 2.5-5 mg over 2 minutes.
*[[Dose]] 2.5-5 mg over 2 minutes.
*Route - Intravenous.
*Route - [[Intravenous therapy|Intravenous]].
*Maximum dose 15 mg.
*Maximum dose 15 mg.
*Doses can be repeated over 5 minutes interval.
*[[dose|Doses]] can be repeated over 5 minutes interval.
 
======Esmolol======
=====Esmolol=====
*Short duration of action (10-20 min).
*Short duration of action (10-20 min).
*Metabolized by RBC esterases.
*Metabolized by [[Red blood cell|RBC]] esterases.
*Advantage - It can be used in conditions where patient's response and tolerance to beta blocker is uncertain. If there is a concern that beta-blockade may cause decompensated heart failure, hypotension, or bradycardia, the short half-life of esmolol permits a therapeutic trial to check the patient's response. Based on that the patient are started on other long acting beta blockers.
*Advantage - It can be used in conditions where [[patients]]' response and tolerance to [[beta blocker]] are uncertain. If there is a concern that [[beta blocker]] may cause decompensated [[heart failure]], [[hypotension]], or [[bradycardia]], the short [[half-life]] of [[esmolol]] permits a [[therapy|therapeutic trial]] to check the [[patient]]'s response. Based on that the [[patient]] is started on other long-acting [[beta blocker]].
*Doses
*[[dose|Doses]]
**Infusion at rate of 50 µg/kg per min, with an increase in the rate of administration by 50 µg/kg per min every 30 minutes.
**[[Intravenous therapy|Infusion]] at a rate of 50 µg/kg per min, with an increase in the rate of administration by 50 µg/kg per min every 30 minutes.
**Some hospitals prefer starting with a bolus of 0.5 mg/kg over one minute, followed by infusion of 50 µg/kg per min. Monitor for four minutes. In case of inadequate response, another bolus is given followed by an infusion of 100 µg/kg per min.  Wait for 4 minutes.  In case of inadequate response a third bolus can be given followed by an infusion at 150 µg/kg per min rate. The maximum infusion that can be given is 200 µg/kg per min.
**Some hospitals prefer starting with a bolus of 0.5 mg/kg over one minute, followed by an [[Intravenous therapy|infusion]] of 50 µg/kg per min. Monitor for four minutes. Another bolus is given followed by an [Intravenous therapy|infusion]] of 100 µg/kg per min, in case of inadequate response within 4 minutes.  In case of inadequate response, a third bolus can be given followed by an [Intravenous therapy|infusion]] at 150 µg/kg per min rate. The maximum [Intravenous therapy|infusion]] that can be given is 200 µg/kg per min.


====Chronic Beta Blocker Therapy====
=====Chronic Beta Blocker Therapy=====
*Oral beta blockers are preferred for treatment of chronic atrial fibrillation.
*[[mouth|Oral]] [[beta blockers]] are preferred for the [[treatment]] of [[Chronic (medical)|chronic]] [[atrial fibrillation]].
*Commonly used agents are [[Atenolol]] or [[metoprolol]]
*Commonly used agents are [[atenolol]] or [[metoprolol]]
*Atenolol dose - 25 mg per day. Maximum dose permitted is 200 mg per day.
*[[Atenolol]] [[dose]] - 25 mg per day. The maximum [[dose]] permitted is 200 mg per day.
*Metoprolol dose - 25mg to 200mg of short acting (metoprolol tartrate) twice a day or 50mg to 400mg of long acting (metoprolol succinate) daily. Metoprolol succinate is the preferred form due to convenience.
*[[Metoprolol]] [[dose]] - 25mg to 200mg of short-acting ([[metoprolol tartrate]]) twice a day or 50mg to 400mg of long-acting ([[Metoprolol succinate (tablet)|metoprolol succinate]]) daily. [[Metoprolol succinate (tablet)|Metoprolol succinate]] is the preferred form due to convenience.
*[[Carvedilol]] or metoprolol succinate should be used in patients with [[chronic heart failure]] with reduced ejection fraction, since these agents are also indicated for heart failure with reduced ejection fraction.
*[[Carvedilol]] or [[Metoprolol succinate (tablet)|metoprolol succinate]] should be used in [[patients]] with [[chronic heart failure]] with reduced [[ejection fraction]] since these agents are also indicated for [[heart failure]] with reduced [[ejection fraction]].
*[[Amiodarone]] should be avoided for long term rate control in [[patients]] with [[atrial fibrillation]].<ref name="pmid34020968">{{cite journal| author=Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee| title=Atrial fibrillation: diagnosis and management-summary of NICE guidance. | journal=BMJ | year= 2021 | volume= 373 | issue=  | pages= n1150 | pmid=34020968 | doi=10.1136/bmj.n1150 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34020968  }} </ref>


=====Side Effects of Beta Blocker Therapy=====
=====Adverse Effects of Beta Blocker Therapy=====
*[[Congestive heart failure]]: beta-blockers are indicated for chronic treatment of heart failure with reduced ejection fraction, but in the short term they risk causing decompensation of tenuous patients due to negative inotropic effects.
*[[Fatigue]]
*[[Congestive heart failure]]: [[beta blockers]] are indicated for [[Chronic (medical)|chronic]] [[treatment]] of [[heart failure]] with reduced [[ejection fraction]], but in the short term they risk causing [[decompensation]] of tenuous [[patients]] due to negative [[Inotrope|inotropic effects]].
*[[Hypotension]]
*[[Hypotension]]
*[[AV block]]
*[[AV block]]
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====Calcium Channel Blockers====
====Calcium Channel Blockers====
* Nondihydropyridine calcium channel blockers [[verapamil]] and [[diltiazem]] (Cardizem) are commonly used.
* [[calcium channel blocker|Nondihydropyridine calcium channel blockers]] such as [[verapamil]] and [[diltiazem]] ([[Diltiazem|Cardizem]]) are commonly used.
* Diltiazem is common used as a drip for acute rate control when patients present with rapid ventricular response
** [[Calcium-channel blockers]] may be used in combination with [[beta-blockers]] if the [[beta blockers]] alone is not sufficient in achieving rate control. However, [[hypotension]] may complicate combination [[therapy]] in particular in the [[elderly]].
** Dose 15-20mg once, then start drip at 10mg/minute
* [[Diltiazem]] is common used as a drip for acute rate control when [[patients]] present with rapid [[ventricle|ventricular response]]
*Diltiazem can be transitioned from a drip to a short acting oral form (given 4x daily), then a long acting form (given daily)
** [[Dose]] 15-20mg once, then start drip at 10mg/minute
**Immediate release diltiazem is usually dose 30-120mg every 6 hours
*[[Diltiazem]] can be transitioned from a drip to a short-acting [[mouth|oral]] form (given 4x daily), then a long-acting form (given daily)
**Long-acting diltiazem is usually dose 120-480mg daily
**Immediate release [[diltiazem]] is usually dose 30-120mg every 6 hours
*Verapamil is less commonly used, but is also available as both PO and IV formulations
**Long-acting [[diltiazem]] is usually dosed 120-480mg daily
*[[Verapamil]] is less commonly used but is also available as both [[Per os|PO]] and [[intravenous therapy]] formulations.
*Use of [[calcium channel blockers]] is not recommended in [[patients]] with acute [[atrial fibrillation]] who are suspected for [[heart failure|acute decompensated heart failure]].<ref name="pmid34020968">{{cite journal| author=Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee| title=Atrial fibrillation: diagnosis and management-summary of NICE guidance. | journal=BMJ | year= 2021 | volume= 373 | issue=  | pages= n1150 | pmid=34020968 | doi=10.1136/bmj.n1150 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34020968  }} </ref>


==== Digoxin ====
==== Digoxin ====
* Cardiac glycoside with positive inotropic and AV nodal blocking properties (increases vagal tone at the AV node)
* [[Digoxin]] is a [[cardiac glycoside]] with positive [[Inotrope|inotropic]] and [[Atrioventricular node|AV nodal]] blocking properties (which increases vagal tone at the [[atrioventricular node]]).
* Can be useful in patients with heart failure since it is the only ''positive'' inotrope that blocks the AV node. Beta-blockers and calcium channel blockers are negative inotropes.
* Can be useful in [[patients]] with [[heart failure]] since it is the only ''positive'' [[inotrope]] that blocks the [[atrioventricular node]. [[Beta blockers|Beta-blockers]] and [[calcium channel blockers]] are negative [[inotropes]].
* Less favored than beta-blockers or calcium channel blockers due to narrow therapeutic index and concerns about increased mortality in AF patients treated with digoxin in the TREAT-AF study <ref>Mintu P. Turakhia, MD, MAS∗; Pasquale Santangeli, MD†; Wolfgang C. Winkelmayer, MD, MPH, ScD§; Xiangyan Xu, MS∗; Aditya J. Ullal, BA∗; Claire T. Than, MPH∗; Susan Schmitt, PhD∗; Tyson H. Holmes, PhD‖; Susan M. Frayne, MD, MPH∗; Ciaran S. Phibbs, PhD∗; Felix Yang, MD∗∗; Donald D. Hoang, BA∗; P. Michael Ho, MD, PhD††; Paul A. Heidenreich, MD, MS.  Increased Mortality Associated With Digoxin in Contemporary Patients With Atrial FibrillationFindings From the TREAT-AF Study.  JACC 2014;64(7):660-668.</ref>
* Less favored than [[Beta blockers|beta-blockers]] or [[calcium channel blockers]] due to narrow [[therapeutic index]] and concerns about increased [[mortality rate|mortality]] in [[atrial fibrillation]] [[patients]] treated with [[digoxin]] in the TREAT-AF study <ref>Mintu P. Turakhia, MD, MAS∗; Pasquale Santangeli, MD†; Wolfgang C. Winkelmayer, MD, MPH, ScD§; Xiangyan Xu, MS∗; Aditya J. Ullal, BA∗; Claire T. Than, MPH∗; Susan Schmitt, PhD∗; Tyson H. Holmes, PhD‖; Susan M. Frayne, MD, MPH∗; Ciaran S. Phibbs, PhD∗; Felix Yang, MD∗∗; Donald D. Hoang, BA∗; P. Michael Ho, MD, PhD††; Paul A. Heidenreich, MD, MS.  Increased Mortality Associated With Digoxin in Contemporary Patients With Atrial FibrillationFindings From the TREAT-AF Study.  JACC 2014;64(7):660-668.</ref>
 
*[[Digoxin]] [[monotherapy]] could be considered the first line [[treatment]] for rate control in non-paroxysmal [[atrial fibrillation]] in the presence of the following:<ref name="pmid34020968">{{cite journal| author=Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee| title=Atrial fibrillation: diagnosis and management-summary of NICE guidance. | journal=BMJ | year= 2021 | volume= 373 | issue= | pages= n1150 | pmid=34020968 | doi=10.1136/bmj.n1150 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34020968  }} </ref>
==2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation (DO NOT EDIT)<ref name="JanuaryWann2014">{{cite journal|last1=January|first1=C. T.|last2=Wann|first2=L. S.|last3=Alpert|first3=J. S.|last4=Calkins|first4=H.|last5=Cleveland|first5=J. C.|last6=Cigarroa|first6=J. E.|last7=Conti|first7=J. B.|last8=Ellinor|first8=P. T.|last9=Ezekowitz|first9=M. D.|last10=Field|first10=M. E.|last11=Murray|first11=K. T.|last12=Sacco|first12=R. L.|last13=Stevenson|first13=W. G.|last14=Tchou|first14=P. J.|last15=Tracy|first15=C. M.|last16=Yancy|first16=C. W.|title=2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000041}}</ref>==
**[[Patients]] with no or minimal [[physical exercise]]
**[[Patient]] preference
**[[Contraindication]] or exclusion of other rate control [[treatments]] due to other concurrent [[diseases]]


=2024 ESC Guideline for the Management of Patients With Atrial Fibrillation==
====Rate Control====
====Rate Control====
{| class="wikitable" style="width: 80%;"
{| class="wikitable" style="width: 80%;"
|-
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| colspan="1" style="text-align:center; background:LightGreen" |[[European society of cardiology guidelines classification scheme#Classification of Recommendations|Class I]]
|-
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' Control of the [[ventricle|ventricular]] rate using a [[beta blocker]] or [[Calcium channel blocker#Non-dihydropyridine|nondihydropyridine]] [[calcium channel antagonist]] is recommended for patients with paroxysmal, persistent, or permanent [[AF]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
| bgcolor="LightGreen" |'''1.''' Rate control therapy is recommended in patients with [[atrial fibrillation]] as initial therapy in the acute setting, as an adjunct to rhythm control therapies, or as a sole treatment strategy to control heart rate and reduce symptoms. ''([[European society of cardiology guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
|-
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''2.''' [[Intravenous]] administration of a [[beta blocker]] or [[Calcium channel blocker#Non-dihydropyridine|nondihydropyridine calcium channel blocker]] is recommended to slow the ventricular [[heart rate]] in the acute setting in patients without [[pre-excitation]]. In [[hemodynamics|hemodynamically]] unstable patients, electrical [[cardioversion]] is indicated. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
| bgcolor="LightGreen" |'''2.''' [[Beta-blockers]], [[Diltiazem]], [[Verapamil]], or [[Digoxin]] are recommended as first-choice drugs in patients with [[atrial fibrillation]] and LVEF >40% to control heart rate and reduce symptoms. ''([[European society of cardiology guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
|-
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''3.''' In patients who experience [[AF]]-related symptoms during activity, the adequacy of [[heart rate]] control should be assessed during exertion, adjusting pharmacological treatment as necessary to keep the ventricular rate within the physiological range. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
| bgcolor="LightGreen" |'''3.''' [[Beta-blockers]] and/or [[Digoxin]] are recommended in patients with [[atrial fibrillation]] and LVEF ≤40% to control heart rate and reduce symptoms. ''([[European society of cardiology guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
|}
|}


{| class="wikitable" style="width: 80%;"
{| class="wikitable" style="width: 80%;"
|-
|-
| colspan="1" style="text-align:center; background:LightCoral" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III: Harm]]
| colspan="1" style="text-align:center; background:LemonChiffon" |[[European society of cardiology guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|-
| bgcolor="LightCoral" |<nowiki>"</nowiki>'''1.''' [[AV node|AV nodal]] [[ablation]] with permanent ventricular pacing should not be performed to improve rate control without prior attempts to achieve rate control with medications. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
| bgcolor="LemonChiffon" |'''1.''' Combination rate control therapy should be considered if a single drug does not control symptoms or heart rate in patients with [[atrial fibrillation]], providing that [[bradycardia]] can be avoided, to control heart rate and reduce symptoms. ''([[European society of cardiology guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
|-
|-
| bgcolor="LightCoral" |<nowiki>"</nowiki>'''2.''' [[Calcium channel blocker#Non-dihydropyridine|Nondihydropyridine calcium channel antagonists]] should not be used in patients with decompensated [[HF]] as these may lead to further [[hemodynamic]] compromise. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
| bgcolor="LemonChiffon" |'''2.''' Lenient rate control with a resting [[heart rate]] <110 bpm should be considered as the initial target for patients with [[atrial fibrillation]], with stricter control reserved for those with continuing AF-related symptoms. ''([[European society of cardiology guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
|-
|-
| bgcolor="LightCoral" |<nowiki>"</nowiki>'''3.''' In patients with [[pre-excitation]] and [[AF]], [[digoxin]], [[Calcium channel blocker#Non-dihydropyridine|nondihydropyridine calcium channel antagonists]], or [[intravenous]] [[amiodarone]] should not be administered as they may increase the ventricular response and may result in [[ventricular fibrillation]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
| bgcolor="LemonChiffon" |'''3.''' [[Atrioventricular node ablation]] in combination with [[pacemaker]] implantation should be considered in patients unresponsive to, or ineligible for, intensive rate and rhythm control therapy to control heart rate and reduce symptoms. ''([[European society of cardiology guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
|-
|-
| bgcolor="LightCoral" |<nowiki>"</nowiki>'''4.''' [[Dronedarone]] should not be used to control the ventricular rate in patients with permanent [[AF]] as it increases the risk of the combined endpoint of [[stroke]], [[MI]], systemic [[embolism]], or cardiovascular death. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
| bgcolor="LemonChiffon" |'''4.''' [[Atrioventricular node ablation]] combined with [[cardiac resynchronization therapy]] should be considered in severely symptomatic patients with permanent [[atrial fibrillation]] and at least one hospitalization for [[heart failure]] to reduce symptoms, physical limitations, recurrent heart failure hospitalization, and mortality. ''([[European society of cardiology guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
|}
|}


{| class="wikitable" style="width: 80%;"
{| class="wikitable" style="width: 80%;"
|-
|-
| colspan="1" style="text-align:center; background:LemonChiffon" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
| colspan="1" style="text-align:center; background:Khaki" |[[European society of cardiology guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|-
| bgcolor="LemonChiffon" |<nowiki>"</nowiki>'''1.''' A [[heart rate]] control (resting [[heart rate]] <80 bpm) strategy is reasonable for symptomatic management of [[AF]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
| bgcolor="Khaki" |'''1.''' Intravenous [[amiodarone]], [[digoxin]], [[esmolol]], or [[landiolol]] may be considered in patients with [[atrial fibrillation]] who have [[haemodynamic instability]] or severely depressed LVEF to achieve acute control of heart rate. ''([[European society of cardiology guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
|-
| bgcolor="LemonChiffon" |<nowiki>"</nowiki>'''2.''' [[Intravenous]] [[amiodarone]] can be useful for rate control in critically ill patients without [[pre-excitation]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon" |<nowiki>"</nowiki>'''3.''' [[AV node|AV nodal]] [[ablation]] with permanent ventricular pacing is reasonable to control the [[heart rate]] when pharmacological therapy is inadequate and rhythm control is not achievable. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
|}
==Sources==


{| class="wikitable" style="width: 80%;"
* [https://academic.oup.com/eurheartj/article/45/36/3314/7738779 2024 ESC Guidelines for the Management of Atrial Fibrillation]<ref>{{cite journal|last1=Van Gelder|first1=Isabelle C.|last2=Rienstra|first2=Michiel|last3=Bunting|first3=Karina V.|last4=Casado-Arroyo|first4=Ruben|last5=Caso|first5=Valeria|last6=Crijns|first6=Harry J G M|last7=De Potter|first7=Tom J R|last8=Dwight|first8=Jeremy|last9=Guasti|first9=Luigina|last10=Hanke|first10=Thorsten|last11=Jaarsma|first11=Tiny|last12=Lettino|first12=Maddalena|last13=Løchen|first13=Maja-Lisa|last14=Lumbers|first14=R Thomas|last15=Maesen|first15=Bart|last16=Mølgaard|first16=Inge|last17=Rosano|first17=Giuseppe M C|last18=Sanders|first18=Prashanthan|last19=Schnabel|first19=Renate B|last20=Suwalski|first20=Piotr|last21=Svennberg|first21=Emma|last22=Tamargo|first22=Juan|last23=Tica|first23=Otilia|last24=Traykov|first24=Vassil|last25=Tzeis|first25=Stylianos|last26=Kotecha|first26=Dipak|title=2024 ESC Guidelines for the Management of Atrial Fibrillation|journal=European Heart Journal|year=2024|volume=45|issue=36|pages=3314-3403|doi=10.1093/eurheartj/ehaa612|url=https://academic.oup.com/eurheartj/article/45/36/3314/7738779}}</ref>
|-
| colspan="1" style="text-align:center; background:LemonChiffon" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |<nowiki>"</nowiki>'''1.''' A lenient rate-control strategy (resting [[heart rate]] <110 bpm) may be reasonable as long as patients remain asymptomatic and LV systolic function is preserved. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon" |<nowiki>"</nowiki>'''2.''' Oral [[amiodarone]] may be useful for ventricular rate control when other measures are unsuccessful or contraindicated. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
 
==Sources==


* [http://circ.ahajournals.org/content/early/2014/03/27/CIR.0000000000000041 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation]<ref name="JanuaryWann2014">{{cite journal|last1=January|first1=C. T.|last2=Wann|first2=L. S.|last3=Alpert|first3=J. S.|last4=Calkins|first4=H.|last5=Cleveland|first5=J. C.|last6=Cigarroa|first6=J. E.|last7=Conti|first7=J. B.|last8=Ellinor|first8=P. T.|last9=Ezekowitz|first9=M. D.|last10=Field|first10=M. E.|last11=Murray|first11=K. T.|last12=Sacco|first12=R. L.|last13=Stevenson|first13=W. G.|last14=Tchou|first14=P. J.|last15=Tracy|first15=C. M.|last16=Yancy|first16=C. W.|title=2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000041}}</ref>
* [http://circ.ahajournals.org/content/early/2014/03/27/CIR.0000000000000041 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation]<ref name="JanuaryWann2014">{{cite journal|last1=January|first1=C. T.|last2=Wann|first2=L. S.|last3=Alpert|first3=J. S.|last4=Calkins|first4=H.|last5=Cleveland|first5=J. C.|last6=Cigarroa|first6=J. E.|last7=Conti|first7=J. B.|last8=Ellinor|first8=P. T.|last9=Ezekowitz|first9=M. D.|last10=Field|first10=M. E.|last11=Murray|first11=K. T.|last12=Sacco|first12=R. L.|last13=Stevenson|first13=W. G.|last14=Tchou|first14=P. J.|last15=Tracy|first15=C. M.|last16=Yancy|first16=C. W.|title=2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000041}}</ref>
Line 135: Line 129:


*[http://circ.ahajournals.org/content/123/1/104.full.pdf+html 2011 ACCF/AHA/HRS Focused Update on the Management of Patients With Atrial Fibrillation (Updating the 2006 Guideline)] <ref name="pmid21182985">{{cite journal| author=Wann LS, Curtis AB, January CT, Ellenbogen KA, Lowe JE, Estes NA et al.| title=2011 ACCF/AHA/HRS focused update on the management of patients with atrial fibrillation (Updating the 2006 Guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=Heart Rhythm | year= 2011 | volume= 8 | issue= 1 | pages= 157-76 | pmid=21182985 | doi=10.1016/j.hrthm.2010.11.047 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21182985  }} </ref>
*[http://circ.ahajournals.org/content/123/1/104.full.pdf+html 2011 ACCF/AHA/HRS Focused Update on the Management of Patients With Atrial Fibrillation (Updating the 2006 Guideline)] <ref name="pmid21182985">{{cite journal| author=Wann LS, Curtis AB, January CT, Ellenbogen KA, Lowe JE, Estes NA et al.| title=2011 ACCF/AHA/HRS focused update on the management of patients with atrial fibrillation (Updating the 2006 Guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=Heart Rhythm | year= 2011 | volume= 8 | issue= 1 | pages= 157-76 | pmid=21182985 | doi=10.1016/j.hrthm.2010.11.047 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21182985  }} </ref>
==Rhythm Control==
*When rate control is not successful enough or when it is not able to improve the [[symptoms]] of [[patients]] [[cardioversion|rhythm control]] (either [[pharmacology|pharmacological]] or electrical) should be considered. <ref name="pmid34020968">{{cite journal| author=Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee| title=Atrial fibrillation: diagnosis and management-summary of NICE guidance. | journal=BMJ | year= 2021 | volume= 373 | issue=  | pages= n1150 | pmid=34020968 | doi=10.1136/bmj.n1150 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34020968  }} </ref>
*Rhythm control could be considered as a first step [[treatment]] for [[patients]] who developed [[atrial fibrillation]] after a [[heart|cardiac]] [[surgery]].<ref name="pmid34020968">{{cite journal| author=Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee| title=Atrial fibrillation: diagnosis and management-summary of NICE guidance. | journal=BMJ | year= 2021 | volume= 373 | issue=  | pages= n1150 | pmid=34020968 | doi=10.1136/bmj.n1150 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34020968  }} </ref>
*If [[pharmacology|pharmacological]] [[cardioversion]] (rhythm control) has been selected for [[treatment]] of [[patients]] who developed [[atrial fibrillation]] after a [[heart|cardiac]] [[surgery]], reevaluating the necessity for continuing the [[treatment]] should be considered in 6 weeks.<ref name="pmid34020968">{{cite journal| author=Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee| title=Atrial fibrillation: diagnosis and management-summary of NICE guidance. | journal=BMJ | year= 2021 | volume= 373 | issue=  | pages= n1150 | pmid=34020968 | doi=10.1136/bmj.n1150 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34020968  }} </ref>
*To learn more read the [[cardioversion]] section of this micro chapter. ([[Atrial fibrillation cardioversion|Click here]])
==Rate Control versus Rhythm Control==
*Rate control [[treatments]] seek to reduce the [[heart rate]] to normal while allowing the [[patient]] to remain in [[atrial fibrillation]]. A goal of < 110bpm (lenient rate control) is usually targeted, since [[patients]] do not seem to do any better with stricter control<ref>Isabelle C. Van Gelder, M.D., Hessel F. Groenveld, M.D., Harry J.G.M. Crijns, M.D., Ype S. Tuininga, M.D., Jan G.P. Tijssen, Ph.D., A. Marco Alings, M.D., Hans L. Hillege, M.D., Johanna A. Bergsma-Kadijk, M.Sc., Jan H. Cornel, M.D., Otto Kamp, M.D., Raymond Tukkie, M.D., Hans A. Bosker, M.D., Dirk J. Van Veldhuisen, M.D., and Maarten P. Van den Berg, M.D., for the RACE II Investigators* Lenient versus Strict Rate Control in Patients with Atrial Fibrillation. NEJM 2010; 362:1363-1373 April 15, 2010DOI: 10.1056/NEJMoa1001337
</ref>.
*Rhythm control seeks to restore the [[sinus rhythm|normal heart rhythm]], called normal [[sinus rhythm]]. Options for rhythm control include [[Antiarrhythmic agent|anti-arrhythmic medications]] ([[flecainide]], [[amiodarone]], [[sotalol]], and others), catheter-based ablation procedures, and [[surgery|surgical]] ablation procedures.
*Rate control with [[anticoagulation]] was found to be non-inferior to rhythm control in terms of [[mortality|mortality]] outcomes in the AFFIRM Trial.<ref name="pmid12466506">{{cite journal | author=Wyse DG, Waldo AL, DiMarco JP, Domanski MJ, Rosenberg Y, Schron EB, Kellen JC, Greene HL, Mickel MC, Dalquist JE, Corley SD | title=A comparison of rate control and rhythm control in patients with atrial fibrillation | journal=N Engl J Med | year=2002 | pages=1825-33 | volume=347 | issue=23 }} PMID 12466506</ref>
*AFFIRM also showed no reduction in risk of [[stroke]] with rhythm control strategy compared to rate control with [[anticoagulation]].<ref name="pmid12466506" />
*Based on this evidence, a rhythm control strategy is no longer pursued in most [[atrial fibrillation]] [[patients]], since the [[Antiarrhythmic agent|anti-arrhythmic drugs]] can have serious [[Adverse effect (medicine)|side effects]] and [[catheter]] or [[surgery|surgical]] ablation procedures have risks as well.
*Rhythm control may be desired when the [[patient]] is significantly [[symptom|symptomatic]] despite rate control, or if the [[patients]] cannot tolerate rate control [[medications]].


==References==
==References==

Latest revision as of 18:45, 22 October 2024
Resident
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Guide

Atrial Fibrillation Microchapters

Home

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Overview
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Atrial fibrillation rate control On the Web

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US National Guidelines Clearinghouse

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FDA on Atrial fibrillation rate control

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Risk calculators and risk factors for Atrial fibrillation rate control

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2] Anahita Deylamsalehi, M.D.[3] Sem A.O.F. Rikken, M.D.[4]

Overview

Rate and rhythm control is the first step in treatment of hemodynamically stable patients with acute (less than 48 hours) atrial fibrillation. It is also considered as a first step treatment for patients who developed atrial fibrillation after a cardiac surgery.Atrial fibrillation with rapid ventricular rate is a common finding in many hospitalized patients. The ventricular rate may be increased up to 150-170. It is essential to bring the ventricular rate down to less than 110 because a rapid ventricular response can cause hemodynamic instabilities and tachycardia mediated cardiomyopathies (heart failure). Atrial fibrillation (AF) can cause disabling and annoying symptoms. Palpitations, angina, lassitude (weariness), and decreased exercise tolerance are related to rapid heart rate and inefficient cardiac output caused by atrial fibrillation (AF). This can significantly increase mortality and morbidity, which can be prevented by early and adequate treatment of the atrial fibrillation (AF).

Rate Control

Rate control is the first step should be taken in treatment of patients with atrial fibrillation. Based on NICE guideline the exception of this rule is the following conditions:[1]

Rate control could be considered as a first step treatment for patients who developed atrial fibrillation after a cardiac surgery.[1]

Pharmacologic Rate Control


Mechanism of Action

Beta Blockers

Acute Beta Blocker Therapy
Metoprolol
  • Dose 2.5-5 mg over 2 minutes.
  • Route - Intravenous.
  • Maximum dose 15 mg.
  • Doses can be repeated over 5 minutes interval.
Esmolol
  • Short duration of action (10-20 min).
  • Metabolized by RBC esterases.
  • Advantage - It can be used in conditions where patients' response and tolerance to beta blocker are uncertain. If there is a concern that beta blocker may cause decompensated heart failure, hypotension, or bradycardia, the short half-life of esmolol permits a therapeutic trial to check the patient's response. Based on that the patient is started on other long-acting beta blocker.
  • Doses
    • Infusion at a rate of 50 µg/kg per min, with an increase in the rate of administration by 50 µg/kg per min every 30 minutes.
    • Some hospitals prefer starting with a bolus of 0.5 mg/kg over one minute, followed by an infusion of 50 µg/kg per min. Monitor for four minutes. Another bolus is given followed by an [Intravenous therapy|infusion]] of 100 µg/kg per min, in case of inadequate response within 4 minutes. In case of inadequate response, a third bolus can be given followed by an [Intravenous therapy|infusion]] at 150 µg/kg per min rate. The maximum [Intravenous therapy|infusion]] that can be given is 200 µg/kg per min.
Chronic Beta Blocker Therapy
Adverse Effects of Beta Blocker Therapy

Calcium Channel Blockers

Digoxin

2024 ESC Guideline for the Management of Patients With Atrial Fibrillation=

Rate Control

Class I
1. Rate control therapy is recommended in patients with atrial fibrillation as initial therapy in the acute setting, as an adjunct to rhythm control therapies, or as a sole treatment strategy to control heart rate and reduce symptoms. (Level of Evidence: B)
2. Beta-blockers, Diltiazem, Verapamil, or Digoxin are recommended as first-choice drugs in patients with atrial fibrillation and LVEF >40% to control heart rate and reduce symptoms. (Level of Evidence: B)
3. Beta-blockers and/or Digoxin are recommended in patients with atrial fibrillation and LVEF ≤40% to control heart rate and reduce symptoms. (Level of Evidence: B)
Class IIa
1. Combination rate control therapy should be considered if a single drug does not control symptoms or heart rate in patients with atrial fibrillation, providing that bradycardia can be avoided, to control heart rate and reduce symptoms. (Level of Evidence: C)
2. Lenient rate control with a resting heart rate <110 bpm should be considered as the initial target for patients with atrial fibrillation, with stricter control reserved for those with continuing AF-related symptoms. (Level of Evidence: B)
3. Atrioventricular node ablation in combination with pacemaker implantation should be considered in patients unresponsive to, or ineligible for, intensive rate and rhythm control therapy to control heart rate and reduce symptoms. (Level of Evidence: B)
4. Atrioventricular node ablation combined with cardiac resynchronization therapy should be considered in severely symptomatic patients with permanent atrial fibrillation and at least one hospitalization for heart failure to reduce symptoms, physical limitations, recurrent heart failure hospitalization, and mortality. (Level of Evidence: B)
Class IIb
1. Intravenous amiodarone, digoxin, esmolol, or landiolol may be considered in patients with atrial fibrillation who have haemodynamic instability or severely depressed LVEF to achieve acute control of heart rate. (Level of Evidence: B)

Sources

Rhythm Control

Rate Control versus Rhythm Control

References

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee (2021). "Atrial fibrillation: diagnosis and management-summary of NICE guidance". BMJ. 373: n1150. doi:10.1136/bmj.n1150. PMID 34020968 Check |pmid= value (help).
  2. ↑ Mintu P. Turakhia, MD, MAS∗; Pasquale Santangeli, MD†; Wolfgang C. Winkelmayer, MD, MPH, ScD§; Xiangyan Xu, MS∗; Aditya J. Ullal, BA∗; Claire T. Than, MPH∗; Susan Schmitt, PhD∗; Tyson H. Holmes, PhD‖; Susan M. Frayne, MD, MPH∗; Ciaran S. Phibbs, PhD∗; Felix Yang, MD∗∗; Donald D. Hoang, BA∗; P. Michael Ho, MD, PhD††; Paul A. Heidenreich, MD, MS. Increased Mortality Associated With Digoxin in Contemporary Patients With Atrial FibrillationFindings From the TREAT-AF Study. JACC 2014;64(7):660-668.
  3. ↑ Van Gelder, Isabelle C.; Rienstra, Michiel; Bunting, Karina V.; Casado-Arroyo, Ruben; Caso, Valeria; Crijns, Harry J G M; De Potter, Tom J R; Dwight, Jeremy; Guasti, Luigina; Hanke, Thorsten; Jaarsma, Tiny; Lettino, Maddalena; Løchen, Maja-Lisa; Lumbers, R Thomas; Maesen, Bart; Mølgaard, Inge; Rosano, Giuseppe M C; Sanders, Prashanthan; Schnabel, Renate B; Suwalski, Piotr; Svennberg, Emma; Tamargo, Juan; Tica, Otilia; Traykov, Vassil; Tzeis, Stylianos; Kotecha, Dipak (2024). "2024 ESC Guidelines for the Management of Atrial Fibrillation". European Heart Journal. 45 (36): 3314–3403. doi:10.1093/eurheartj/ehaa612.
  4. ↑ January, C. T.; Wann, L. S.; Alpert, J. S.; Calkins, H.; Cleveland, J. C.; Cigarroa, J. E.; Conti, J. B.; Ellinor, P. T.; Ezekowitz, M. D.; Field, M. E.; Murray, K. T.; Sacco, R. L.; Stevenson, W. G.; Tchou, P. J.; Tracy, C. M.; Yancy, C. W. (2014). "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society". Circulation. doi:10.1161/CIR.0000000000000041. ISSN 0009-7322.
  5. ↑ Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2011) 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 123 (10):e269-367. DOI:10.1161/CIR.0b013e318214876d PMID: 21382897
  6. ↑ Wann LS, Curtis AB, January CT, Ellenbogen KA, Lowe JE, Estes NA; et al. (2011). "2011 ACCF/AHA/HRS focused update on the management of patients with atrial fibrillation (Updating the 2006 Guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Heart Rhythm. 8 (1): 157–76. doi:10.1016/j.hrthm.2010.11.047. PMID 21182985.
  7. ↑ Isabelle C. Van Gelder, M.D., Hessel F. Groenveld, M.D., Harry J.G.M. Crijns, M.D., Ype S. Tuininga, M.D., Jan G.P. Tijssen, Ph.D., A. Marco Alings, M.D., Hans L. Hillege, M.D., Johanna A. Bergsma-Kadijk, M.Sc., Jan H. Cornel, M.D., Otto Kamp, M.D., Raymond Tukkie, M.D., Hans A. Bosker, M.D., Dirk J. Van Veldhuisen, M.D., and Maarten P. Van den Berg, M.D., for the RACE II Investigators* Lenient versus Strict Rate Control in Patients with Atrial Fibrillation. NEJM 2010; 362:1363-1373 April 15, 2010DOI: 10.1056/NEJMoa1001337
  8. ↑ 8.0 8.1 Wyse DG, Waldo AL, DiMarco JP, Domanski MJ, Rosenberg Y, Schron EB, Kellen JC, Greene HL, Mickel MC, Dalquist JE, Corley SD (2002). "A comparison of rate control and rhythm control in patients with atrial fibrillation". N Engl J Med. 347 (23): 1825–33. PMID 12466506


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