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| [[File:Siren.gif|30px|link=Atrial fibrillation resident survival guide]]|| <br> || <br>
| [[Atrial fibrillation resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
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{{Atrial fibrillation}}
{{Atrial fibrillation}}
{{CMG}}; '''Associate Editor-In-Chief:''' {{CZ}}
{{CMG}}; {{AE}} {{CZ}} {{Anahita}} {{SemRikken}}


==Rate control==
==Overview==
Rate control is achieved with medications that work by increasing the degree of block at the level of the AV node, effectively decreasing the number of impulses that conduct down into the ventricles. This can be accomplisheddone with:
[[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]]).
* [[Beta blockers]] (preferably the "cardioselective" beta blockers such as [[metoprolol]], [[atenolol]], [[bisoprolol]])
==Rate Control==
* [[Cardiac glycosides]] (i.e. [[digoxin]])
[[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>
* [[Calcium channel blocker]]s (i.e. [[diltiazem]] or [[verapamil]])
*If [[atrial fibrillation]] is due to a reversible condition
*When [[heart failure]] due to [[atrial fibrillation]] has developed
*In new onset [[atrial fibrillation]]
*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
[[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===
*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]]


In addition to these agents, [[amiodarone]] has some AV node blocking effects (particularly when administered intravenously), and can be used in individuals when other agents are contraindicated or ineffective (particularly due to [[hypotension]]).
====Mechanism of Action====
*[[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]].
:*[[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.
:*[[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.


==Rate control versus rhythm control==
====Beta Blockers====
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. Furthermore, AF with a persistent rapid rate can cause a form of [[heart failure]] called [[tachycardia induced cardiomyopathy]]. This can significantly increase mortality and morbidity, which can be prevented by early and adequate treatment of the AF.
=====Acute Beta Blocker Therapy=====
*[[Intravenous therapy|Intravenous]] [[beta blocker]] like [[metoprolol]] and [[esmolol]].
*Useful when [[atrial fibrillation]] is secondary to high adrenergic tone like in [[operation|post operative]] situations.
======Metoprolol======
*[[Dose]] 2.5-5 mg over 2 minutes.
*Route - [[Intravenous therapy|Intravenous]].
*Maximum dose 15 mg.
*[[dose|Doses]] can be repeated over 5 minutes interval.
======Esmolol======
*Short duration of action (10-20 min).
*Metabolized by [[Red blood cell|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 [[therapy|therapeutic trial]] to check the [[patient]]'s response. Based on that the [[patient]] is started on other long-acting [[beta blocker]].
*[[dose|Doses]]
**[[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 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.


There are two ways to approach these symptoms: rate control and rhythm control. ''Rate control'' treatments seek to reduce the heart rate to normal, usually 60 to 100 beats per minute. ''Rhythm control'' seeks to restore the normal heart rhythm, called normal sinus rhythm. Studies suggest that rhythm control is mainly a concern in newly diagnosed AF, while rate control is more important in the chronic phase.  Rate control with anticoagulation is as effective a treatment as rhythm control in long term mortality studies, 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>
=====Chronic Beta Blocker Therapy=====
*[[mouth|Oral]] [[beta blockers]] are preferred for the [[treatment]] of [[Chronic (medical)|chronic]] [[atrial fibrillation]].
*Commonly used agents are [[atenolol]] or [[metoprolol]]
*[[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 (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]].
*[[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>


The AFFIRM study showed no difference in risk of stroke in patients who have converted to a normal rhythm with anti-arrhythmic treatment, compared to those who have only rate control.<ref name=pmid12466506/>
=====Adverse Effects of Beta Blocker Therapy=====
*[[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]]
*[[AV block]]
*[[Bradycardia]]
*[[Bronchospasm]]


==ACC / AHA Guidelines- Pharmacological Rate Control During Atrial Fibrillation (DO NOT EDIT) <ref name="Epstein"> Epstein AE, DiMarco JP, Ellenbogen KA, Estes NAM III, Freedman RA, Gettes LS, Gillinov AM, Gregoratos G, Hammill SC, Hayes DL, Hlatky MA, Newby LK, Page RL, Schoenfeld MH, Silka MJ, Stevenson LW, Sweeney MO. ACC/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices). Circulation. 2008; 117: 2820–2840. PMID 18483207 </ref>==
====Calcium Channel Blockers====
{{cquote|
* [[calcium channel blocker|Nondihydropyridine calcium channel blockers]] such as [[verapamil]] and [[diltiazem]] ([[Diltiazem|Cardizem]]) are commonly used.
===Class I===
** [[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]].
1. Measurement of the heart rate at rest and control of the rate using pharmacological agents (either a [[beta blocker]] or non [[dihydropyridine]] [[calcium channel antagonist]], in most cases) are recommended for patients with persistent or permanent [[AF]]. ''(Level of Evidence: B)''
* [[Diltiazem]] is common used as a drip for acute rate control when [[patients]] present with rapid [[ventricle|ventricular response]]
** [[Dose]] 15-20mg once, then start drip at 10mg/minute
*[[Diltiazem]] can be transitioned from a drip to a short-acting [[mouth|oral]] form (given 4x daily), then a long-acting form (given daily)
**Immediate release [[diltiazem]] is usually dose 30-120mg every 6 hours
**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>


2. Intravenous administration of [[digoxin]] or [[amiodarone]] is recommended to control the heart rate in patients with [[AF]] and [[heart failure]] who do not have an accessory pathway. ''(Level of Evidence: B)''
==== Digoxin ====
* [[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]].
* 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]]


3. In patients who experience symptoms related to [[AF]] during activity, the adequacy of heart rate control should be assessed during exercise, adjusting pharmacological treatment as necessary to keep the rate in the physiological range. ''(Level of Evidence: C)''
=2024 ESC Guideline for the Management of Patients With Atrial Fibrillation==
====Rate Control====
{| class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[European society of cardiology guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| 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" |'''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" |'''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]])''
|}


4. [[Digoxin]] is effective following oral administration to control the heart rate at rest in patients with [[AF]] and is indicated for patients with [[heart failure]], [[LV dysfunction]], or for sedentary individuals. ''(Level of Evidence: C)''
{| class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[European society of cardiology guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| 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="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="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="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 IIa===
{| class="wikitable" style="width: 80%;"
1. A combination of [[digoxin]] and either a [[beta blocker]] or non [[dihydropyridine]] [[calcium channel antagonist]] is reasonable to control the heart rate both at rest and during exercise in patients with [[AF]]. The choice of medication should be individualized and the dose modulated to avoid [[bradycardia]]. ''(Level of Evidence: B)''
|-
 
| colspan="1" style="text-align:center; background:Khaki" |[[European society of cardiology guidelines classification scheme#Classification of Recommendations|Class IIb]]
2. It is reasonable to use [[ablation]] of the [[AV node]] or accessory pathway to control heart rate when pharmacological therapy is insufficient or associated with side effects. ''(Level of Evidence: B)''
|-
 
| 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]])''
3. Intravenous [[amiodarone]] can be useful to control the heart rate in patients with [[AF]] when other measures are unsuccessful or contraindicated. ''(Level of Evidence: C)''
|}
==Sources==


4. When electrical [[cardioversion]] is not necessary in patients with [[AF]] and an accessory pathway, intravenous [[procainamide]] or [[ibutilide]] is a reasonable alternative. ''(Level of Evidence: C)''
* [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>


===Class IIb===
* [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>
1. When the ventricular rate cannot be adequately controlled both at rest and during exercise in patients with [[AF]] using a [beta blocker]], non [[dihydropyridine]] [[calcium channel antagonist]], or [[digoxin]], alone or in combination, oral [[amiodarone]] may be administered to control the heart rate. ''(Level of Evidence: C)''


2. Intravenous [[procainamide]], [[disopyramide]], [[ibutilide]], or [[amiodarone]] may be considered for hemodynamically stable patients with [[AF]] involving conduction over an accessory pathway. ''(Level of Evidence: B)''
*[http://circ.ahajournals.org/content/123/10/e269.full.pdf 2011 ACCF/AHA/HRS Focused Updates Incorporated Into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation] <ref name="pmid21382897">Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2011) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=21382897 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. [http://dx.doi.org/10.1161/CIR.0b013e318214876d DOI:10.1161/CIR.0b013e318214876d] PMID: [http://pubmed.gov/21382897 21382897]</ref>


3. When the rate cannot be controlled with pharmacological agents or [[tachycardia]]-mediated [[cardiomyopathy]] is suspected, [[catheter ablation|catheter-directed ablation]] of the [[AV node]] may be considered in patients with [[AF]] to control the heart rate. ''(Level of Evidence: C)''
*[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>
 
===Class III===
1. [[Digitalis]] should not be used as the sole agent to control the rate of ventricular response in patients with paroxysmal [[AF]]. ''(Level of Evidence: B)''


2. [[Catheter ablation]] of the [[AV node]] should not be attempted without a prior trial of medication to control the ventricular rate in patients with [[AF]]. ''(Level of Evidence: C)''
==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]])


3. In patients with decompensated [[heart failure|HF]] and [[AF]], intravenous administration of a non [[dihydropyridine]] [[calcium channel antagonist]] may exacerbate hemodynamic compromise and is not recommended. ''(Level of Evidence: C)''
==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
4. Intravenous administration of [[digitalis]] [[glycoside]]s or non [[dihydropyridine]] [[calcium channel antagonists]] to patients with [[AF]] and a [[pre-excitation syndrome]] may paradoxically accelerate the ventricular response and is not recommended. ''(Level of Evidence: C)''}}
</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.
==See Also==
*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>
* [[The Living Guidelines: Diagnosis and Management of Atrial Fibrillation | The AF Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines]]
*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.
==Sources==
*Rhythm control may be desired when the [[patient]] is significantly [[symptom|symptomatic]] despite rate control, or if the [[patients]] cannot tolerate rate control [[medications]].
* The ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation <ref name="Fuster"> Fuster V, Ryden LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, Halperin JL, Le Heuzey JY, Kay GN, Lowe JE, Olsson SB, Prystowsky EN, Tamargo JL, Wann S. ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation- Executive Summary: executive summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidlines for the Management of Patients With Atrial Fibrillation): Developed in Collaboration With the European Heart Rhythm Association and the Heart Rhythm Society. Circulation. 2006; 114: 700-752. PMID 16908781 </ref>


==References==
==References==
{{reflist|2}}
{{reflist|2}}


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[[Category:Electrophysiology]]
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[[it:Fibrillazione atriale]]
[[nl:Boezemfibrilleren]]
[[ja:心房細動]]
[[no:Atrieflimmer]]
[[pl:Migotanie przedsionków]]
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Latest revision as of 18:45, 22 October 2024
Resident
Survival
Guide

Atrial Fibrillation Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Atrial Fibrillation from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Special Groups

Postoperative AF
Acute Myocardial Infarction
Wolff-Parkinson-White Preexcitation Syndrome
Hypertrophic Cardiomyopathy
Hyperthyroidism
Pulmonary Diseases
Pregnancy
ACS and/or PCI or valve intervention
Heart failure

Diagnosis

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

EKG Examples
A-Fib with LBBB

Chest X Ray

Echocardiography

Holter Monitoring and Exercise Stress Testing

Cardiac MRI

Treatment

Rate and Rhythm Control

Cardioversion

Overview
Electrical Cardioversion
Pharmacological Cardioversion

Anticoagulation

Overview
Warfarin
Converting from or to Warfarin
Converting from or to Parenteral Anticoagulants
Dabigatran

Maintenance of Sinus Rhythm

Surgery

Catheter Ablation
AV Nodal Ablation
Surgical Ablation
Cardiac Surgery

Specific Patient Groups

Primary Prevention

Secondary Prevention

Supportive Trial Data

Cost-Effectiveness of Therapy

Case Studies

Case #1

Atrial fibrillation rate control On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Atrial fibrillation rate control

CDC on Atrial fibrillation rate control

Atrial fibrillation rate control in the news

Blogs on Atrial fibrillation rate control

Directions to Hospitals Treating Atrial fibrillation rate control

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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