From the Guidelines
Atrial fibrillation with a high heart rate should be managed with rate control medications as the initial therapy, using beta-blockers, diltiazem, verapamil, or digoxin, with the goal of reducing symptoms and heart rate, as recommended by the 2024 ESC guidelines 1. The choice of rate control medication depends on the patient's left ventricular ejection fraction (LVEF), with beta-blockers, diltiazem, verapamil, or digoxin recommended for patients with LVEF >40% 1. For patients with LVEF ≤40%, beta-blockers and/or digoxin are recommended 1. Key considerations in the management of atrial fibrillation include:
- Comorbidity and risk factor management
- Avoiding stroke and thromboembolism
- Reducing symptoms through rate and rhythm control
- Evaluation and dynamic reassessment 1 The target heart rate should be less than 110 beats per minute at rest, and anticoagulation therapy should be considered to prevent stroke, with options including warfarin, apixaban, rivaroxaban, or dabigatran, depending on the patient's CHA₂DS₂-VASc score 1. Rhythm control with cardioversion or antiarrhythmic drugs may be considered for patients with persistent symptoms despite rate control, with the goal of reducing symptoms and improving quality of life 1. Patients should be monitored for symptoms of heart failure, stroke, or medication side effects during treatment, and the management plan should be periodically reassessed to ensure optimal outcomes 1.
From the Research
Atrial Fibrillation with High Heart Rate
- Atrial fibrillation (AF) with rapid ventricular rate (RVR) is a common condition that requires acute management to control the heart rate and prevent complications.
- The choice of medication for rate control in AF with RVR is crucial, with beta-blockers (e.g., metoprolol) and nondihydropyridine calcium channel blockers (e.g., diltiazem) being commonly used options.
Comparison of Metoprolol and Diltiazem
- A study published in 2022 2 compared the efficacy and safety of intravenous metoprolol and diltiazem for rate control in AF with RVR, finding no significant difference in the achievement of rate control between the two groups.
- Another study published in 2015 3 found that diltiazem was more effective in achieving rate control in patients with AF with RVR, with a faster and more substantial decrease in heart rate compared to metoprolol.
- A systematic review and meta-analysis published in 2024 4 found that metoprolol was associated with a lower risk of adverse events (including hypotension and bradycardia) compared to diltiazem.
Considerations in Patients with Heart Failure
- A study published in 2022 5 found that in patients with AF with RVR and heart failure, diltiazem reduced heart rate more quickly and effectively than metoprolol, with no difference in safety outcomes.
- Another study published in 2006 6 found that in patients with atrial fibrillation and advanced chronic heart failure, lower heart rates were associated with a worse outcome, suggesting that higher heart rates may not be unfavorable in this population.
Adverse Events and Safety
- The risk of adverse events, including hypotension and bradycardia, is an important consideration when choosing a medication for rate control in AF with RVR.
- Studies have found that metoprolol may be associated with a lower risk of adverse events compared to diltiazem 4, although the difference in safety outcomes between the two medications is not always significant 2, 5.