What beta blocker is recommended for rapid atrial fibrillation in a patient with Chronic Obstructive Pulmonary Disease (COPD)?

From the Guidelines

Beta blockers should be used cautiously for rate control in rapid atrial fibrillation in patients with COPD, with cardioselective agents being preferred, as recommended by the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation 1.

Key Considerations

• Metoprolol (starting at 25-50 mg twice daily) or bisoprolol (2.5-5 mg once daily) are good initial choices as they primarily target beta-1 receptors in the heart with minimal effect on beta-2 receptors in the lungs 1.
• Start with low doses and titrate slowly while monitoring for bronchospasm, especially in patients with severe COPD or a history of bronchospasm.
• For acute rate control in the emergency setting, IV metoprolol (5 mg slow IV push, repeated up to 3 times if needed) may be used with close monitoring 1.

Alternative Options

• Non-dihydropyridine calcium channel blockers like diltiazem or verapamil, which don't affect bronchial tone but require caution in patients with heart failure, can be considered as alternative rate control options 1.
• Despite theoretical concerns, evidence suggests that cardioselective beta blockers are generally well-tolerated in COPD patients and may even reduce mortality and exacerbations in those with concurrent cardiovascular disease.

Monitoring and Adjustments

• Regular pulmonary function monitoring is recommended during initiation and dose adjustments to ensure the patient's respiratory status remains stable.
• The choice of medication and dosage should be individualized based on the patient's specific condition, medical history, and response to treatment, as outlined in the 2014 AHA/ACC/HRS guideline 1.

From the FDA Drug Label

The maximal effect occurred within 1-4 hours post-dosing. Effects persisted for 24 hours at doses equal to or greater than 5 mg Electrophysiology studies in man have demonstrated that bisoprolol fumarate significantly decreases heart rate, increases sinus node recovery time, prolongs AV node refractory periods, and, with rapid atrial stimulation, prolongs AV nodal conduction. Pulmonary function studies have been conducted in healthy volunteers, asthmatics, and patients with chronic obstructive pulmonary disease (COPD). Doses of bisoprolol fumarate ranged from 5 to 60 mg... In some studies, slight, asymptomatic increases in airways resistance (AWR) and decreases in forced expiratory volume (FEV 1) were observed with doses of bisoprolol fumarate 20 mg and higher, similar to the small increases in AWR also noted with the other cardioselective beta-blockers.

Bisoprolol can be used as a beta blocker for rapid atrial fibrillation. However, in patients with COPD, it should be used with caution due to potential effects on pulmonary function, including slight increases in airways resistance and decreases in forced expiratory volume. The beta 1-selectivity of bisoprolol may help minimize these effects. Key points to consider:

• Dosing: 5 mg or greater
• Onset of action: 1-4 hours
• Duration of action: 24 hours
• Pulmonary effects: slight, asymptomatic increases in airways resistance and decreases in forced expiratory volume at doses of 20 mg or higher 2

From the Research

Beta Blockers for Rapid Atrial Fibrillation in COPD

• The use of beta blockers in atrial fibrillation has been studied, and they have been shown to be effective in maintaining sinus rhythm and controlling ventricular rate 3.
• In patients with persistent atrial fibrillation, AV-nodal conduction-slowing drugs, such as calcium channel antagonists and beta blockers, are used to control the ventricular rate during atrial fibrillation 3.
• For rate control in atrial fibrillation with rapid ventricular response, beta blockers such as metoprolol and calcium channel blockers such as diltiazem are effective options 4, 5.
• In patients with COPD, the prevalence of atrial fibrillation is high, and COPD may promote atrial fibrillation and impair treatment efficacy 6.
• The choice of beta blocker for rate control in atrial fibrillation in patients with COPD should be individualized, considering the patient's clinical situation and comorbidities 4, 5.
• Studies have compared the efficacy and safety of intravenous metoprolol and diltiazem for rate control in atrial fibrillation, with no significant difference in rate control achievement between the two agents 5.
• In patients with heart failure with reduced ejection fraction, beta blockers such as metoprolol may be preferred over calcium channel blockers such as diltiazem due to their potential negative inotropic effects 7.

Considerations for COPD Patients

• COPD may increase the risk of atrial fibrillation and impair treatment efficacy 6.
• The diagnosis and treatment of COPD in patients with atrial fibrillation require close interdisciplinary collaboration between electrophysiologists/cardiologists and pulmonologists 6.
• Routine evaluation of lung function and determination of natriuretic peptides and echocardiography may be reasonable to detect COPD and heart failure as contributing causes of dyspnea 6.
• Acute exacerbation of COPD may transiently increase the risk of atrial fibrillation due to hypoxia-mediated mechanisms, inflammation, increased use of beta-2 agonists, and autonomic changes 6.