Atrial fibrillation rate control: Difference between revisions
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{{Atrial fibrillation}} | {{Atrial fibrillation}} | ||
{{CMG}}; | {{CMG}}; {{AE}} {{CZ}} | ||
==Overview== | ==Overview== | ||
[[Atrial fibrillation]] with rapid ventricular rate is a common finding in many hospitalized patients. The ventricular rate may be increased upto 150-170. 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 [[cardiomyopathy|cardiomyopathies]] ([[heart failure]]). AF can cause disabling and annoying symptoms. [[Palpitations]], [[Angina pectoris|angina]], lassitude (weariness), and decreased exercise tolerance are related to [[rapid heart rate]] and inefficient [[cardiac output]] caused by AF. This can significantly increase mortality and morbidity, which can be prevented by early and adequate treatment of the AF. | [[Atrial fibrillation]] with rapid ventricular rate is a common finding in many hospitalized patients. The ventricular rate may be increased upto 150-170. 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 [[cardiomyopathy|cardiomyopathies]] ([[heart failure]]). AF can cause disabling and annoying symptoms. [[Palpitations]], [[Angina pectoris|angina]], lassitude (weariness), and decreased exercise tolerance are related to [[rapid heart rate]] and inefficient [[cardiac output]] caused by AF. This can significantly increase mortality and morbidity, which can be prevented by early and adequate treatment of the AF. | ||
==Rate Control== | ==Rate Control== | ||
===Rate Control versus Rhythm Control=== | ===Rate Control versus Rhythm Control=== | ||
There are two ways to approach symptoms: rate control and 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, usually 60 to 100 beats per minute. | *Rate control treatments seek to reduce the [[heart rate]] to normal, usually 60 to 100 beats per minute. | ||
* Rhythm control seeks to restore the [[sinus rhythm|normal heart rhythm]], called normal [[sinus rhythm]]. | *Rhythm control seeks to restore the [[sinus rhythm|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. | *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> | *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> | ||
* 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/> | *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/> | ||
===Pharmacologic Rate Control=== | ===Pharmacologic Rate Control=== | ||
====Mechanism of Action==== | ====Mechanism of Action==== | ||
*Rate control is achieved with medications that work by increasing the degree of block at the [[AV node]], effectively decreasing the number of impulses that conduct to the ventricles. This can be accomplished with: | *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 blocker]]s (i.e. [[diltiazem]] or [[verapamil]]) block the influx of calcium and reduce the upstroke of the action potential. | :*[[Calcium channel blocker]]s (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. | :*[[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. | :*[[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]]). | :*[[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. | :*[[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. | :*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. | ||
====Beta Blockers==== | ====Beta Blockers==== | ||
=====Acute Beta Blocker Therapy===== | =====Acute Beta Blocker Therapy===== | ||
* Intravenous beta blocker like [[metoprolol]], [[propranolol]], and [[esmolol]]. | *Intravenous beta blocker like [[metoprolol]], [[propranolol]], 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. | ||
* Maximum dose 15 mg. | *Maximum dose 15 mg. | ||
* Doses can be repeated over 5 minutes interval. | *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 RBC esterases. | ||
* Advantage - It can be used in conditions where patient's response and tolerance to beta blocker is uncertain for e.g [[bradycardia]]. In these situations its short half-life permits a therapeutic trial to check the patient's response. Based on that the patient are started on other long acting beta blockers. | *Advantage - It can be used in conditions where patient's response and tolerance to beta blocker is uncertain for e.g [[bradycardia]]. In these situations its short half-life permits a therapeutic trial to check the patient's response. Based on that the patient are started on other long acting beta blockers. | ||
* Doses | *Doses | ||
** Infusion at rate of 50 µg/kg per min, with an increase in the rate of administration by 50 µg/kg per min every 30 minutes. | **Infusion at rate of 50 µg/kg per min, with an increase in the rate of administration by 50 µg/kg per min every 30 minutes. | ||
** Some hospitals prefer starting with a bolus of 0.5 mg/kg over one minute, followed by infusion of 50 µg/kg per min. Monitor for four minutes. In case of inadequate response, another bolus is given followed by an infusion of 100 µg/kg per min. Wait for 4 minutes. In case of inadequate response a third bolus can be given followed by an infusion at 150 µg/kg per min rate. The maximum infusion that can be given is 200 µg/kg per min. | **Some hospitals prefer starting with a bolus of 0.5 mg/kg over one minute, followed by infusion of 50 µg/kg per min. Monitor for four minutes. In case of inadequate response, another bolus is given followed by an infusion of 100 µg/kg per min. Wait for 4 minutes. In case of inadequate response a third bolus can be given followed by an infusion at 150 µg/kg per min rate. The maximum infusion that can be given is 200 µg/kg per min. | ||
====Chronic Beta Blocker Therapy==== | ====Chronic Beta Blocker Therapy==== | ||
* Oral beta blockers are preferred for treatment of chronic atrial fibrillation. | *Oral beta blockers are preferred for treatment of chronic atrial fibrillation. | ||
* Commonly used agents are: [[Atenolol]], [[metoprolol]], [[timolol]], [[pindolol]], [[nadolol]] and [[labetalol]]. | *Commonly used agents are: [[Atenolol]], [[metoprolol]], [[timolol]], [[pindolol]], [[nadolol]] and [[labetalol]]. | ||
* Atenolol is the preferred over other agents due to its long half life, once daily dose, and less CNS side effects. | *Atenolol is the preferred over other agents due to its long half life, once daily dose, and less CNS side effects. | ||
* Atenolol dose - 25 mg per day. Maximum dose permitted is 200 mg per day. | *Atenolol dose - 25 mg per day. Maximum dose permitted is 200 mg per day. | ||
* [[Carvedilol]] has been found to be useful in patients with [[chronic heart failure]] due to systolic dysfunction. | *[[Carvedilol]] has been found to be useful in patients with [[chronic heart failure]] due to systolic dysfunction. | ||
=====Side Effects of Beta Blocker Therapy===== | =====Side Effects of Beta Blocker Therapy===== | ||
* [[Congestive heart failure]] | *[[Congestive heart failure]] | ||
* [[Hypotension]] | *[[Hypotension]] | ||
* [[AV block]] | *[[AV block]] | ||
* [[Bradycardia]] | *[[Bradycardia]] | ||
* [[Bronchospasm]] | *[[Bronchospasm]] | ||
====Calcium Channel Blockers==== | ====Calcium Channel Blockers==== | ||
| Line 123: | Line 123: | ||
| 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 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]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | ||
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Revision as of 19:12, 9 September 2013
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Atrial fibrillation rate control On the Web | |
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Directions to Hospitals Treating Atrial fibrillation rate control | |
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Risk calculators and risk factors for Atrial fibrillation rate control | |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]
Overview
Atrial fibrillation with rapid ventricular rate is a common finding in many hospitalized patients. The ventricular rate may be increased upto 150-170. 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 (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
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, 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.[1]
- 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.[1]
Pharmacologic Rate Control
Mechanism of Action
- Rate control is achieved with medications that work by increasing the degree of block at the AV node, effectively decreasing the number of impulses that conduct to the ventricles. This can be accomplished with:
- 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.
Beta Blockers
Acute Beta Blocker Therapy
- Intravenous beta blocker like metoprolol, propranolol, and esmolol.
- Useful when atrial fibrillation is secondary to high adrenergic tone like in post operative situations.
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 patient's response and tolerance to beta blocker is uncertain for e.g bradycardia. In these situations its short half-life permits a therapeutic trial to check the patient's response. Based on that the patient are started on other long acting beta blockers.
- Doses
- Infusion at rate of 50 µg/kg per min, with an increase in the rate of administration by 50 µg/kg per min every 30 minutes.
- Some hospitals prefer starting with a bolus of 0.5 mg/kg over one minute, followed by infusion of 50 µg/kg per min. Monitor for four minutes. In case of inadequate response, another bolus is given followed by an infusion of 100 µg/kg per min. Wait for 4 minutes. In case of inadequate response a third bolus can be given followed by an infusion at 150 µg/kg per min rate. The maximum infusion that can be given is 200 µg/kg per min.
Chronic Beta Blocker Therapy
- Oral beta blockers are preferred for treatment of chronic atrial fibrillation.
- Commonly used agents are: Atenolol, metoprolol, timolol, pindolol, nadolol and labetalol.
- Atenolol is the preferred over other agents due to its long half life, once daily dose, and less CNS side effects.
- Atenolol dose - 25 mg per day. Maximum dose permitted is 200 mg per day.
- Carvedilol has been found to be useful in patients with chronic heart failure due to systolic dysfunction.
Side Effects of Beta Blocker Therapy
Calcium Channel Blockers
2011 ACCF/AHA/HRS Focused Updates Incorporated Into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation (DO NOT EDIT)[2]
Pharmacological Rate Control (DO NOT EDIT)[2]
| 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 III: No Benefit |
| "1. Treatment to achieve strict rate control of heart rate (<80 bpm at rest or <110 bpm during a 6-minute walk) is not beneficial compared to achieving a resting heart rate <110 bpm in patients with persistent AF who have stable ventricular function (LV ejection fraction >0.40) and no or acceptable symptoms related to the arrhythmia, though uncontrolled tachycardia may over time be associated with a reversible decline in ventricular performance. (Level of Evidence: B)" |
| Class III: Harm |
| "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)" |
| 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)" |
Sources
- 2011 ACCF/AHA/HRS Focused Updates Incorporated Into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation [2]
- 2011 ACCF/AHA/HRS Focused Update on the Management of Patients With Atrial Fibrillation (Updating the 2006 Guideline) [3]
References
- ↑ 1.0 1.1 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
- ↑ 2.0 2.1 2.2 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
- ↑ 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.