How to control atrial fibrillation in a 65-year-old female with recent diagnosis, hypotension, and highly variable heart rate, currently on Bisoprolol (beta blocker) 2.5 mg, Ivabradine (anti-arrhythmic) 2.5 mg, Oseltamivir (antiviral) 150 mg twice daily, and Formoterol (bronchodilator) twice daily?

From the Guidelines

Controlling atrial fibrillation in a 65-year-old female with recent diagnosis, hypotension, and highly variable heart rate requires a multifaceted approach, with a primary focus on rate control using beta blockers, such as Bisoprolol, which she is already taking, and potentially adding or adjusting other medications like digoxin or nondihydropyridine calcium channel antagonists.

Key Considerations

• The patient's current medication regimen includes Bisoprolol (beta blocker) 2.5 mg and Ivabradine (anti-arrhythmic) 2.5 mg, which are both used for rate control in atrial fibrillation.
• Given her hypotension, caution is necessary when adjusting or adding medications that can further lower blood pressure.
• The use of Oseltamivir (antiviral) and Formoterol (bronchodilator) should be evaluated for potential interactions or effects on heart rate and rhythm.

Rate Control Strategies

• Beta blockers: Bisoprolol is a suitable choice, but the dose may need adjustment based on her response and tolerance, considering her hypotension 1.
• Nondihydropyridine calcium channel antagonists: These can be considered for rate control, especially if beta blockers are not tolerated or are insufficient, but with caution due to potential hypotensive effects 1.
• Digoxin: May be useful for controlling resting heart rate, especially in patients with heart failure, but its use requires careful monitoring of levels due to the narrow therapeutic index 1.

Rhythm Control Considerations

• Rhythm control strategies, including antiarrhythmic drugs, cardioversion, or catheter ablation, may be considered based on the patient's symptoms, quality of life, and specific clinical circumstances, but the primary approach for this patient, given the recent diagnosis and variable heart rate, should focus on achieving adequate rate control 1.

Anticoagulation

• The decision for anticoagulation should be based on the patient's risk of thromboembolism, assessed using tools like the CHA2DS2-VASc score, and her risk of bleeding 1.

Monitoring and Adjustment

• Regular monitoring of the patient's heart rate, rhythm, blood pressure, and symptoms is crucial to adjust the treatment plan as necessary.
• The patient's medication regimen should be regularly reviewed for potential interactions, especially with the use of Oseltamivir and Formoterol, and adjustments made to optimize atrial fibrillation management while minimizing risks 1.

The FDA Drug Labels for Bisoprolol (PO), Ivabradine (PO), Oseltamivir (PO), Formoterol (INH) do not address this question.

From the Research

Controlling Atrial Fibrillation

To control atrial fibrillation in a 65-year-old female with recent diagnosis, hypotension, and highly variable heart rate, the following approaches can be considered:

• The patient is currently on Bisoprolol (beta blocker) 2.5 mg and Ivabradine (anti-arrhythmic) 2.5 mg, which are commonly used for rate control in atrial fibrillation 2, 3.
• According to the study by 4, immediate direct-current cardioversion should be performed in persons with AF associated with hypotension.
• The use of beta blockers, such as Bisoprolol, is effective in reducing exercise heart rate and can be used to control the ventricular rate in atrial fibrillation 2, 3.
• Ivabradine can be used in combination with beta blockers to further reduce the heart rate if necessary 3.
• The study by 5 suggests that oral warfarin should be given for 3 weeks before elective direct-current or drug cardioversion of AF and continued for at least 4 weeks after maintenance of sinus rhythm, unless transesophageal echocardiography has shown no thrombus in the left atrial appendage before cardioversion.
• The patient's current medication regimen, including Oseltamivir (antiviral) 150 mg twice daily and Formoterol (bronchodilator) twice daily, should be reviewed to ensure that there are no potential interactions with the medications used to control atrial fibrillation.

Rate Control Strategies

The choice of rate control strategy depends on the symptoms and clinical characteristics of the patient:

• Beta blockers, alone or in combination with digoxin, or non-dihydropyridine calcium-channel blockers can effectively lower the heart rate 3.
• Digoxin is least effective, but a reasonable choice for physically inactive patients aged 80 years or older, in whom other treatments are ineffective or are contraindicated, and as an additional drug to other rate-controlling drugs, especially in heart failure when instituted cautiously 3.
• Atrioventricular node ablation with pacemaker insertion for rate control should be used as an approach of last resort but is also an option early in the management of patients with atrial fibrillation treated with cardiac resynchronisation therapy 3.

Considerations for Older Patients

In older patients, ventricular rate control plus warfarin may be preferred over maintaining sinus rhythm with antiarrhythmic drugs 4, 5.

• Patients with chronic or paroxysmal AF at high risk for stroke should be treated with long-term warfarin to achieve an International Normalized Ratio of 2.0 to 3.0 4, 5.
• Patients with AF at low risk for stroke or with contraindications to warfarin should be treated with aspirin 325 mg daily 4, 5.