Atrial fibrillation rate control: Difference between revisions

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{{Atrial fibrillation}}
{{Atrial fibrillation}}
{{CMG}}; {{AE}} {{CZ}} {{Anahita}}
{{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 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>
[[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>
*If [[atrial fibrillation]] is due to a reversible condition
*If [[atrial fibrillation]] is due to a reversible condition
*When [[heart failure]] due to [[atrial fibrillation]] has developed
*When [[heart failure]] due to [[atrial fibrillation]] has developed
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*In the presence of a [[atrial flutter]] that could be restored to [[sinus rhythm]] with [[ablation]] [[therapy]]
*In the presence of a [[atrial flutter]] that could be restored to [[sinus rhythm]] with [[ablation]] [[therapy]]
*In conditions that clinical judgment prefer rhythm control  
*In conditions that clinical judgment prefer rhythm control  
[[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>
===Pharmacologic Rate Control===
===Pharmacologic Rate Control===
The [[ventricle|ventricular rate]] in [[atrial fibrillation]] is a major determinant of [[symptoms]] and [[Hemodynamics|hemodynamic consequences]]. The [[ventricle|ventricular rate]] is usually reduced by using [[Atrioventricular node|atrioventricular nodal]]-blocking agents. First-line [[therapy|therapies]] include [[beta blockers]] and [[Calcium channel blocker|nondihydropyridine calcium-channel blockers]] ([[verapamil]] and [[diltiazem]]).  
*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>
Specific [[Adverse effect (medicine)|adverse effects]] of each [[medication]] should be taken into consideration when choosing appropriate [[therapy]] for each individual [[patient]].  
*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]]
 
   
   
====Mechanism of Action====
====Mechanism of Action====
*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:
*[[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 [[beta blockers|cardioselective beta blockers]] such as [[metoprolol]], [[atenolol]], [[bisoprolol]]) slow conduction by decreasing [[Sympathetic nervous system|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 nervous system|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 [[Antiarrhythmic agent|class III anti-arrhythmic drug]] which also has [[atrioventricular node]] blocking effects. [[Amiodarone]] can be used for 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.
:*[[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====
=====Acute Beta Blocker Therapy=====
=====Acute Beta Blocker Therapy=====
*[[Intravenous 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.
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*[[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.
*[[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 (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]].
*[[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>


=====Adverse Effects of Beta Blocker Therapy=====
=====Adverse Effects of Beta Blocker Therapy=====
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**Long-acting [[diltiazem]] is usually dosed 120-480mg daily
**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.
*[[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 [[Inotrope|inotropic]] and [[Atrioventricular node|AV nodal]] blocking properties (increases vagal tone at the [[atrioventricular 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 [[atrioventricular node]. [[Beta blockers|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|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>
* 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>
**[[Patients]] with no or minimal [[physical exercise]]
**[[Patient]] preference
**[[Contraindication]] or exclusion of other rate control [[treatments]] due to other concurrent [[diseases]]


==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>==
=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 [[atrial fibrillation]]. ''([[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 [[ventricle|ventricular]] 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 [[atrial fibrillation]]-related [[symptoms]] during activity, the adequacy of [[heart rate]] control should be assessed during exertion, adjusting [[pharmacology|pharmacological]] [[treatment]] as necessary to keep the [[ventricle|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.''' [[Atrioventricular node|AV nodal]] [[ablation]] with permanent [[ventricle|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 [[heart failure]] 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 [[atrial fibrillation]], [[digoxin]], [[Calcium channel blocker#Non-dihydropyridine|nondihydropyridine calcium channel antagonists]], or [[intravenous]] [[amiodarone]] should not be administered as they may increase the [[ventricle|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 [[ventricle|ventricular rate]] in [[patients]] with permanent [[atrial fibrillation]] as it increases the risk of the combined endpoint of [[stroke]], [[ST elevation myocardial infarction
| 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]])''
|MI]], systemic [[embolism]], or cardiovascular death. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
|}


{| 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 [[symptoms|symptomatic]] management of [[atrial fibrillation]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| 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.''' [[atrioventricular node|AV nodal]] [[ablation]] with permanent [[ventricle|ventricular]] pacing is reasonable to control the [[heart rate]] when [[pharmacology|pharmacological]] [[therapy]] is inadequate and rhythm control is not achievable. ''([[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]])''
|}
 
{| class="wikitable" style="width: 80%;"
|-
| 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 [[symptom|asymptomatic]] and [[left ventricle]] systolic function is preserved. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon" |<nowiki>"</nowiki>'''2.''' [[mouth|Oral]] [[amiodarone]] may be useful for [[ventricle|ventricular]] rate control when other measures are unsuccessful or [[contraindication|contraindicated]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
|}
==Sources==


==Sources==
* [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>


* [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 133: 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==
==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 versus Rhythm Control==

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

Atrial Fibrillation Microchapters

Home

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Atrial fibrillation rate control On the Web

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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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