From the Guidelines
Neither olmesartan nor losartan are suitable choices for beta blockers in atrial fibrillation (AFib) management, as they are angiotensin II receptor blockers (ARBs). For AFib, the recommended beta blockers include metoprolol, carvedilol, bisoprolol, or atenolol, as stated in the 2024 ESC guidelines for the management of atrial fibrillation 1. Metoprolol is often the first choice, typically starting at 25-50 mg twice daily and titrating up as needed based on heart rate response. Beta blockers work in AFib by slowing the heart rate through blocking beta-adrenergic receptors, which helps control symptoms and improve cardiac function. Some key points to consider when choosing a beta blocker for AFib include:
- The patient's left ventricular ejection fraction (LVEF), as beta-blockers and/or digoxin are recommended for patients with LVEF ≤40% 1
- The presence of comorbidities such as hypertension or heart failure, where ARBs like olmesartan and losartan may be used in addition to beta blockers
- Monitoring for potential side effects including fatigue, hypotension, and bradycardia, and adjusting the dose accordingly to achieve a target resting heart rate of 60-100 beats per minute While older guidelines such as the 2016 ESC guidelines for the management of atrial fibrillation also recommend beta-blockers for rate control in AFib 1, the most recent guidelines from 2024 should be prioritized for clinical decision-making.
From the Research
Beta Blockers in Atrial Fibrillation
- The use of beta-blockers in atrial fibrillation (AF) is well-established, with metoprolol being a commonly used agent 2, 3.
- Beta-blockers are effective in maintaining sinus rhythm and controlling the ventricular rate during AF 2.
- Metoprolol succinate is associated with significant mortality and morbidity benefits in the treatment of heart failure, which is often comorbid with AF 3.
- The choice of beta-blocker may depend on the specific clinical context, with some studies suggesting that super-selective beta-1 blockers may be superior for target heart rate reduction 4.
Comparison with Other Agents
- Beta-blockers may be used in combination with other agents, such as digoxin, to control the ventricular rate during AF 2, 5.
- The use of intravenous beta-blockers, such as metoprolol, may be compared to other agents, such as diltiazem, in the management of acute AF 5, 4.
- The efficacy and safety of beta-blockers may be influenced by their beta-1 selectivity, with super-selective agents potentially offering improved outcomes 4.
Specific Beta Blockers
- Metoprolol is a commonly used beta-blocker in AF, with a long history of use and a well-established safety profile 2, 3.
- Other beta-blockers, such as bisoprolol, carvedilol, and nebivolol, may also be used in the management of heart failure and AF, although their specific roles and benefits may vary 6.
- The choice of beta-blocker should be individualized based on the patient's specific clinical context and comorbidities 6.
Olmesartan or Losartan
- There is no direct evidence to suggest that olmesartan or losartan should be used to guide the choice of beta-blocker in AF 2, 5, 3, 6, 4.
- These agents are angiotensin II receptor blockers, which are used to treat hypertension and heart failure, but their use is not directly related to the choice of beta-blocker in AF.