What is the best treatment approach for a patient with rapid atrial fibrillation (afib)?

From the Guidelines

The best treatment approach for a patient with rapid atrial fibrillation involves a two-pronged strategy: rate control followed by rhythm control, with consideration for stroke prevention, as recommended by the most recent guidelines 1.

Key Considerations

• Rate control medications such as beta-blockers, calcium channel blockers, or digoxin should be administered to reduce ventricular response, with beta-blockers being the preferred agents for achieving rate control unless otherwise contraindicated 1.
• For rhythm control, options include electrical cardioversion for hemodynamically unstable patients or pharmacological cardioversion with agents like amiodarone, flecainide, or propafenone.
• Anticoagulation therapy is crucial for stroke prevention, with options including warfarin, direct oral anticoagulants like apixaban, rivaroxaban, or dabigatran, and the CHA₂DS₂-VASc score should guide anticoagulation decisions 1.

Treatment Selection

• Treatment selection should be individualized based on patient characteristics, comorbidities, hemodynamic stability, and duration of atrial fibrillation, as these factors influence both the effectiveness of interventions and the risk-benefit profile of different therapeutic approaches.
• The AF-CARE pathway, which includes comorbidity and risk factor management, avoiding stroke and thromboembolism, reducing symptoms by rate and rhythm control, and evaluation and dynamic reassessment, should be followed 1.

Rhythm Control

• Rhythm control should be considered in all suitable AF patients, explicitly discussing with patients all potential benefits and risks of cardioversion, antiarrhythmic drugs, and catheter or surgical ablation to reduce symptoms and morbidity 1.
• Catheter ablation should be considered as a second-line option if antiarrhythmic drugs fail to control AF, or as a first-line option in patients with paroxysmal AF.

From the FDA Drug Label

Diltiazem Hydrochloride Injection or Diltiazem Hydrochloride for Injection are indicated for the following: Atrial Fibrillation or Atrial Flutter Temporary control of rapid ventricular rate in atrial fibrillation or atrial flutter Unless otherwise contraindicated, appropriate vagal maneuvers should be attempted prior to administration of diltiazem hydrochloride injection In domestic controlled trials in patients with atrial fibrillation or atrial flutter, bolus administration of diltiazem hydrochloride injection was effective in reducing heart rate by at least 20% in 95% of patients.

The best treatment approach for a patient with rapid atrial fibrillation (afib) is to attempt vagal maneuvers first, if not contraindicated. If vagal maneuvers are unsuccessful, diltiazem hydrochloride injection can be considered for temporary control of the rapid ventricular rate. This treatment approach is supported by the effectiveness of diltiazem hydrochloride injection in reducing heart rate by at least 20% in 95% of patients with atrial fibrillation or atrial flutter in domestic controlled trials 2. Key considerations include:

• Monitoring of the ECG and frequent measurement of blood pressure
• Availability of a defibrillator and emergency equipment
• Caution in patients who are compromised hemodynamically or taking other drugs that decrease peripheral resistance, myocardial filling, myocardial contractility, or electrical impulse propagation in the myocardium.

From the Research

Treatment Approaches for Rapid Atrial Fibrillation

The treatment of rapid atrial fibrillation (afib) aims to reduce symptoms, prevent embolism, and manage underlying heart disease. The approach can be broadly categorized into rate control and rhythm control.

Rate Control

• Rate control is often the preferred approach, especially in patients over 65 or those with coronary heart disease 3.
• Medications used for rate control include digoxin, beta-blockers (except sotalol), and calcium channel blockers (diltiazem or verapamil) 3, 4.
• Beta-blockers, such as metoprolol, are effective in controlling the ventricular rate at rest and during exercise 5.
• Diltiazem has been shown to be more effective than metoprolol in achieving rate control in the emergency department setting 6.

Rhythm Control

• Rhythm control involves the use of antiarrhythmic drugs to restore and maintain sinus rhythm.
• Medications used for rhythm control include amiodarone, disopyramide, flecainide, quinidine, and sotalol 3, 4.
• Amiodarone has been shown to be effective in restoring and maintaining sinus rhythm, but it can have serious adverse effects 3.
• Rhythm control may be considered in symptomatic, recent, or paroxysmal atrial fibrillation in patients under 65 without signs or symptoms of coronary heart disease 3.

Other Considerations

• Anticoagulant or antiplatelet therapy is essential in preventing embolism, regardless of the treatment approach 3, 4.
• Treatment of underlying heart disease is also crucial in managing atrial fibrillation 3.
• Intravenous procainamide has been shown to be safe and effective in converting atrial fibrillation or flutter to sinus rhythm in the emergency department setting 7.