From the Guidelines
Atrial fibrillation (AFib) treatment should prioritize rate control with beta-blockers, diltiazem, verapamil, or digoxin as first-choice drugs in patients with AF and LVEF >40% to control heart rate and reduce symptoms, as recommended by the 2024 ESC guidelines 1.
Key Considerations
- Rate control therapy is recommended in patients with AF, as initial therapy in the acute setting, an adjunct to rhythm control therapies, or as a sole treatment strategy to control heart rate and reduce symptoms 1.
- Beta-blockers, diltiazem, verapamil, or digoxin are recommended as first-choice drugs in patients with AF and LVEF >40% to control heart rate and reduce symptoms 1.
- Atrioventricular node ablation combined with cardiac resynchronization therapy should be considered in severely symptomatic patients with permanent AF and at least one hospitalization for HF to reduce symptoms, physical limitations, recurrent HF hospitalization, and mortality 1.
Treatment Strategies
- Rate control: beta-blockers like metoprolol or calcium channel blockers such as diltiazem are commonly used to slow the heart rate to 60-100 beats per minute at rest.
- Rhythm control may include antiarrhythmic medications or electrical cardioversion to restore normal sinus rhythm.
- Stroke prevention: anticoagulation therapy is recommended for patients with a CHA₂DS₂-VASc score of 2 or higher.
Lifestyle Modifications
- Reducing alcohol intake
- Managing sleep apnea
- Controlling hypertension
- In persistent cases, catheter ablation may be considered to isolate the pulmonary veins and prevent irregular electrical signals from triggering AFib.
Individualized Treatment
- Treatment should be individualized based on symptoms, age, and comorbidities, with the goal of improving quality of life and reducing complications like stroke and heart failure.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Treatment Options for Atrial Fibrillation
- Drug choices for rate control include beta-blockers, verapamil and diltiazem, and digitalis as first-line agents, with consideration of other sympatholytics, amiodarone, or nonpharmacologic approaches in resistant cases 2
- Anticoagulation may be accomplished with aspirin or warfarin, with the latter preferred in all older or high-risk patients 2
- Antiarrhythmic drug therapy may be used to produce cardioversion, facilitate electrical conversion, prevent early reversion after cardioversion, maintain sinus rhythm during chronic therapy, and/or facilitate conversion of fibrillation to flutter 2
Rate Control in Atrial Fibrillation
- Diltiazem likely achieves rate control faster than metoprolol, though both agents seem safe and effective 3
- Beta blockers (BB) were found to decrease the heart rate after 5 hours vs. 8 hours for calcium channel blockers (CCB) 4
- Patients diagnosed with new-onset AF exhibited shorter duration of hospitalization after therapy with BB compared to CCB 4
Comprehensive Review of Atrial Fibrillation Treatment
- Current therapy for AF mainly includes drug therapy, catheter ablation, cryoballoon ablation, left atrial appendage closure and the maze procedure 5
- The goal of treatment is to prevent and control AF, and management has evolved in recent years to better prevent and control AF 5
Assessment of Efficacy in Rate Control
- The clinical target of rate control should be a ventricular rate below 80-90 bpm at rest 6
- Assessment of the appropriateness of different drugs should include exercise testing and 24h-Holter monitoring 6
- Rate control is considered a valid alternative to rhythm control, and recent prospective trials have shown that in selected patients, rate control provides similar benefits, more economically, in terms of quality of life and long-term mortality 6