Atrial fibrillation rate control

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Overview

Atrial fibrillation with rapid ventricular rate is a common finding in many hospitalized patients. The ventricular rate may be increased upto 150-160. It is essential to bring the ventricular rate down to less than 100 because a rapid ventricular response can cause hemodynamic instabilities and tachycardia mediated cardiomyopathies.

Pharmacologic Rate control

• Rate control is achieved with medications that work by increasing the degree of block at the AV node, effectively decreasing the number of impulses that conduct to the ventricles. This can be accomplished with:

• Calcium channel blockers (i.e. 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
• Cardiac glycosides (i.e. digoxin) are vagomimetics and slow conduction by increasing parasympathetic effects on the node
• Amiodarone has some AV node blocking effects, and can be used in individuals when other agents are contraindicated or ineffective (particularly due to hypotension).
• Adenosine slows conduction by increasing potassium conduction and decreasing calcium entry
• Carotid massage, Valsalva maneuver, and edrophonium though non-pharmacological methods are used sometimes. They slow conduction by increasing the parasympathetic tone on the AV node

Rate control versus rhythm control

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.
• 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.

ACCF/AHA/HRS 2011 Guidelines- Pharmacological Rate Control During Atrial Fibrillation (DO NOT EDIT)

“

Class I 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) 2. In the absence of preexcitation, intravenous administration of beta blockers (esmolol, metoprolol, or propranolol) or nondihydropyridine calcium channel antagonists (verapamil, diltiazem) is recommended to slow the ventricular response to AF in the acute setting, exercising caution in patients with hypotension or heart failure. (Level of Evidence: B) 3. 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) 4. 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) 5. 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 IIa 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) 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) 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) 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) Class IIb 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) 3. When the rate cannot be controlled with pharmacological agents or tachycardia-mediated cardiomyopathy is suspected, catheter-directed ablation of the AV node may be considered in patients with AF to control the heart rate. (Level of Evidence: C) 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) 3. In patients with decompensated HF and AF, intravenous administration of a non dihydropyridine calcium channel antagonist may exacerbate hemodynamic compromise and is not recommended. (Level of Evidence: C) 4. Intravenous administration of digitalis glycosides 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)

”

Vote on and Suggest Revisions to the Current Guidelines

• The AF Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines

Guideline Resources

• ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation

• 2011 ACCF/AHA/HRS Focused Updates Incorporated Into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation

References

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