Atrial fibrillation rate control

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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

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]

Pharmacologic Rate Control


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)[3]

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. 1.0 1.1 1.2 1.3 1.4 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. 3.0 3.1 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.
  4. 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
  5. 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.
  6. 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
  7. 7.0 7.1 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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