From the Guidelines
The drug of choice for rapid atrial fibrillation is typically beta-blockers, diltiazem, verapamil, or digoxin, with the specific choice depending on the patient's left ventricular ejection fraction (LVEF) and other comorbidities, as recommended by the 2024 ESC guidelines 1. For patients with LVEF >40%, beta-blockers, diltiazem, verapamil, or digoxin are recommended as first-choice drugs to control heart rate and reduce symptoms 1.
- Beta-blockers, such as metoprolol, can be given as 5 mg IV over 2-5 minutes, repeated up to 3 times (total 15 mg) as needed.
- Diltiazem can be given as an initial bolus of 0.25 mg/kg (typically 15-20 mg) over 2 minutes, followed by a continuous infusion at 5-15 mg/hour if needed. For patients with LVEF ≤40%, beta-blockers and/or digoxin are recommended to control heart rate and reduce symptoms 1. In hemodynamically unstable patients with rapid atrial fibrillation, immediate synchronized cardioversion is indicated rather than medication. After rate control is achieved, anticoagulation should be considered based on stroke risk factors, and a long-term management strategy (rate vs. rhythm control) should be determined. The choice between agents depends on the patient's comorbidities, with beta-blockers being preferred in patients with coronary artery disease and calcium channel blockers often avoided in heart failure with reduced ejection fraction.
From the Research
Drug Options for Rapid Atrial Fibrillation (AFib)
- The choice of drug for rapid AFib depends on the symptoms and clinical characteristics of the patient 2.
- Short and rapid-onset-acting beta-blockers are suitable for acute rate control, with landiolol being a newer option with a favorable pharmacokinetic and pharmacodynamic profile 3.
- Diltiazem is a preferred agent for rate control in atrial fibrillation due to its quick onset, minimal side effects, and low cost 4.
- Metoprolol and verapamil are also options for rate control, with no significant difference in achieving rate control compared to diltiazem 4, 5.
- In patients taking chronic beta-blocker therapy, IV diltiazem may be associated with a higher rate of successful response to rate control compared to IV metoprolol 6.
Comparison of Drug Options
- A study comparing IV diltiazem and metoprolol found similar blood pressure reduction and hypotension, but rate control was achieved more often with diltiazem 5.
- Another study found that IV diltiazem was associated with a greater incidence of bradycardia compared to IV metoprolol 6.
- The choice of drug should be patient-dependent, considering factors such as symptoms, clinical characteristics, and potential side effects 2.
Key Findings
- Rate control is a top priority in the management of atrial fibrillation, and the choice of drug depends on individual patient characteristics 2.
- Beta-blockers, non-dihydropyridine calcium-channel blockers, and digoxin are effective options for rate control, but the choice of drug should be tailored to the patient's needs 2.
- Landiolol and diltiazem are suitable options for acute rate control, with landiolol having a favorable pharmacokinetic and pharmacodynamic profile 3, 4.