What is the next best step for a patient with persistent atrial fibrillation (AFib) who is intolerant to metoprolol (beta-blocker) and has stopped taking flecainide (anti-arrhythmic), with plans for a Holter monitor?

From the Guidelines

The next best step for a patient with persistent atrial fibrillation who is intolerant to metoprolol and has discontinued flecainide would be to initiate a non-dihydropyridine calcium channel blocker such as diltiazem or verapamil for rate control, as recommended by the 2024 ESC guidelines for the management of atrial fibrillation 1.

Key Considerations

• Diltiazem can be started at 120-360 mg daily in divided doses, while verapamil typically begins at 120-360 mg daily.
• These medications effectively slow conduction through the AV node, controlling ventricular rate without the side effects the patient experienced with metoprolol.
• The planned Holter monitor should proceed to evaluate the effectiveness of rate control and assess the burden of atrial fibrillation.

Rhythm Control Options

• For rhythm control, consider alternative antiarrhythmic options such as amiodarone (starting at 400-600 mg daily for 2-4 weeks, then 200 mg daily) or dronedarone (400 mg twice daily) if the patient remains symptomatic despite adequate rate control, as suggested by previous guidelines 1.
• If pharmacological management proves ineffective, referral for catheter ablation should be considered, particularly if the patient is experiencing significant symptoms or reduced quality of life.

Prioritizing Patient Care

• The primary goal is to reduce symptoms and improve quality of life, while also considering the risk of thromboembolism and the need for anticoagulation, as emphasized in the 2024 ESC guidelines 1.
• A patient-centered approach, with joint decision-making and a multidisciplinary team, is essential for optimal management of atrial fibrillation.

From the Research

Next Steps for Patient with Persistent AFib

• The patient has been taking flecainide for high heart rate due to low blood pressures and cannot tolerate metoprolol, so the next step is to plan for a Holter monitor as already decided.
• According to 2, a Holter monitor is a portable way of taking an electrical trace of the heartbeat over a period of time, usually 24 hours, while the patient goes about their normal day-to-day activities.
• The Holter monitor can help pick up if the heartbeat is too fast, too slow, or irregular, as stated in 2.

Alternative Rate Control Options

• Since the patient is intolerant to metoprolol, alternative rate control options should be considered, such as diltiazem, as suggested in 3, which may achieve rate control faster than metoprolol.
• Calcium channel blockers and β-blockers are effective for rate control in patients with AF with rapid ventricular response, as shown in 3.
• The choice of medication should be based on the individual patient, clinical situation, and comorbidities, as recommended in 3.

Rhythm Control vs. Rate Control

• The study 4 suggests that rate control is often better than rhythm control in patients with atrial fibrillation, especially in those over 65 or with coronary heart disease.
• Rhythm control may cause more adverse events than rate control, as stated in 4, and may not reduce the risk of death or serious cardiovascular events.
• However, in symptomatic, recent, or paroxysmal atrial fibrillation in patients under 65 with no signs or symptoms of coronary heart disease, an attempt should be made to restore sinus rhythm with amiodarone and/or electrical cardioversion, as suggested in 4.