Atrial fibrillation rate control: Difference between revisions

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


==Overview==
==Overview==
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==Rate Control==
==Rate Control==
===Rate Control versus Rhythm Control===
There are two ways to approach symptoms: rate control and rhythm control.
*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
</ref>.
*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.
*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>
*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 AF patients, since the anti-arrhythmic drugs can have serious side effects and catheter or surgical ablation procedures have risks as well.
*Rhythm control may be desired when the patient is significantly symptomatic despite rate control, or if the patients cannot tolerate rate control medications.


===Pharmacologic Rate Control===
===Pharmacologic Rate Control===
The ventricular rate in atrial fibrillation is a major determinant of symptoms and hemodynamic consequences. The ventricular rate is usually reduced by using atrioventricular nodal-blocking agents. First-line therapies include beta-blockers and nondihydropyridine calcium-channel blockers (verapamil and diltiazem).  
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]]).  
Specific adverse effects of each medication should be taken into consideration when choosing appropriate therapy for each individual patient.  
Specific [[Adverse effect (medicine)|adverse effects]] of each [[medication]] should be taken into consideration when choosing appropriate [[therapy]] for each individual [[patient]].  
   
   
====Mechanism of Action====
====Mechanism of Action====
*Rate control is achieved with medications that work by increasing the degree of the block at the [[AV node]], effectively decreasing the number of impulses that conduct to the ventricles. This can be accomplished with:
*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 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 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 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 patients' response and tolerance to beta-blocker are 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 is 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 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.
**[[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 infusion of 50 µg/kg per min. Monitor for four minutes. Another bolus is given followed by an 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 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 the 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. The 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]].


=====Adverse Effects of Beta Blocker Therapy=====
=====Adverse Effects of Beta Blocker Therapy=====
*[[Fatigue]]
*[[Fatigue]]
*[[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.
*[[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.
** [[Calcium-channel blockers]] may be used in combination with [[beta-blockers]] if the [[beta-blocker]] alone is not sufficient in achieving rate control. However, [[hypotension]] may complicate combination therapy in particular in the [[elderly]].  
** [[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]].  
* [[Diltiazem]] is common used as a drip for acute rate control when patients present with rapid ventricular response
* [[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
** [[Dose]] 15-20mg once, then start drip at 10mg/minute
*[[Diltiazem]] can be transitioned from a drip to a short-acting oral form (given 4x daily), then a long-acting form (given daily)
*[[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
**Immediate release [[diltiazem]] is usually dose 30-120mg every 6 hours
**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 PO and IV formulations.
*[[Verapamil]] is less commonly used but is also available as both [[Per os|PO]] and [[intravenous therapy]] formulations.


==== Digoxin ====
==== Digoxin ====
* Cardiac glycoside with positive inotropic and AV nodal blocking properties (increases vagal tone at the AV node)
* [[Cardiac glycoside]] with positive [[Inotrope|inotropic]] and [[Atrioventricular node|AV nodal]] blocking properties (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>


==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>==
==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>==
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| 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" |[[ACC AHA 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" |<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" |<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" |<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" |<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" |<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>
|}
|}


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| 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:LightCoral" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III: Harm]]
|-
|-
| 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="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="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="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="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="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="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="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
|MI]], systemic [[embolism]], or cardiovascular death. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
|}


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| 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:LemonChiffon" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|-
| 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="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>'''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>
| 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>
|}
|}


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| colspan="1" style="text-align:center; background:LemonChiffon" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
| 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>'''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.''' 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>
| 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>
|}
|}


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*[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==
==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==

Revision as of 17:32, 3 August 2021
Resident
Survival
Guide

Atrial Fibrillation Microchapters

Home

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Overview

Historical Perspective

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Differentiating Atrial Fibrillation from other Diseases

Epidemiology and Demographics

Risk Factors

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Natural History, Complications and Prognosis

Special Groups

Postoperative AF
Acute Myocardial Infarction
Wolff-Parkinson-White Preexcitation Syndrome
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A-Fib with LBBB

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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
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Supportive Trial Data

Cost-Effectiveness of Therapy

Case Studies

Case #1

Atrial fibrillation rate control On the Web

Most recent articles

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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]

Overview

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). 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 AF. This can significantly increase mortality and morbidity, which can be prevented by early and adequate treatment of the AF.

Rate Control

Pharmacologic Rate Control

The ventricular rate in atrial fibrillation is a major determinant of symptoms and hemodynamic consequences. The ventricular rate is usually reduced by using atrioventricular nodal-blocking agents. First-line therapies include beta blockers and nondihydropyridine calcium-channel blockers (verapamil and diltiazem). Specific adverse effects of each medication should be taken into consideration when choosing appropriate therapy for each individual patient.

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:

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

2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation (DO NOT EDIT)[2]

Rate Control

Class I
"1. Control of the ventricular rate using a beta blocker or nondihydropyridine calcium channel antagonist is recommended for patients with paroxysmal, persistent, or permanent atrial fibrillation. (Level of Evidence: B) "
"2. Intravenous administration of a beta blocker or nondihydropyridine calcium channel blocker is recommended to slow the ventricular rate in the acute setting in patients without pre-excitation. In hemodynamically unstable patients, electrical cardioversion is indicated. (Level of Evidence: B) "
"3. In patients who experience atrial fibrillation-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. (Level of Evidence: C) "
Class III: Harm
"1. AV nodal ablation with permanent ventricular pacing should not be performed to improve rate control without prior attempts to achieve rate control with medications. (Level of Evidence: C)"
"2. Nondihydropyridine calcium channel antagonists should not be used in patients with decompensated heart failure as these may lead to further hemodynamic compromise. (Level of Evidence: C)"
"3. In patients with pre-excitation and atrial fibrillation, digoxin, nondihydropyridine calcium channel antagonists, or intravenous amiodarone should not be administered as they may increase the ventricular response and may result in ventricular fibrillation. (Level of Evidence: B)"
"4. Dronedarone should not be used to control the ventricular rate in patients with permanent atrial fibrillation as it increases the risk of the combined endpoint of stroke, [[ST elevation myocardial infarction MI]], systemic embolism, or cardiovascular death. (Level of Evidence: B)"
Class IIa
"1. A heart rate control (resting heart rate <80 bpm) strategy is reasonable for symptomatic management of atrial fibrillation. (Level of Evidence: B)"
"2. Intravenous amiodarone can be useful for rate control in critically ill patients without pre-excitation. (Level of Evidence: B)"
"3. 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. (Level of Evidence: B)"
Class IIb
"1. A lenient rate-control strategy (resting heart rate <110 bpm) may be reasonable as long as patients remain asymptomatic and left ventricle systolic function is preserved. (Level of Evidence: B)"
"2. Oral amiodarone may be useful for ventricular rate control when other measures are unsuccessful or contraindicated. (Level of Evidence: C)"

Sources

Rhythm Control

Rate Control versus Rhythm Control

References

  1. ↑ 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.
  2. ↑ 2.0 2.1 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.
  3. ↑ 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
  4. ↑ 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.
  5. ↑ 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
  6. ↑ 6.0 6.1 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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