From the Guidelines
The management of atrial fibrillation (AFib) should prioritize rate control therapy as initial treatment, using beta-blockers, diltiazem, verapamil, or digoxin as first-choice drugs to control heart rate and reduce symptoms, as recommended by the 2024 ESC guidelines 1.
Key Strategies for AFib Management
The management of AFib focuses on three key strategies: rate control, rhythm control, and stroke prevention.
- Rate control: beta-blockers or calcium channel blockers are first-line options to maintain heart rate below 110 bpm at rest.
- Rhythm control: antiarrhythmic medications or electrical cardioversion may be used in symptomatic patients.
- Stroke prevention: anticoagulation based on CHA₂DS₂-VASc score, with direct oral anticoagulants (DOACs) preferred over warfarin for non-valvular atrial fibrillation.
Rate Control Therapy
According to the 2024 ESC guidelines, 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.
- 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.
Rhythm Control and Stroke Prevention
While the 2024 ESC guidelines primarily focus on rate control, previous guidelines such as the 2016 ESC guidelines provide additional insights into rhythm control and stroke prevention 1.
- Rhythm control therapy is indicated for symptom improvement in patients with AF, and may involve electrical or pharmacological cardioversion, long-term antiarrhythmic drug therapy, or catheter ablation.
- Stroke prevention is crucial, with anticoagulation based on CHA₂DS₂-VASc score, and DOACs like apixaban, rivaroxaban, dabigatran, or edoxaban are preferred over warfarin for non-valvular atrial fibrillation.
From the FDA Drug Label
The protocol for ROCKET AF did not stipulate anticoagulation after study drug discontinuation, but warfarin patients who completed the study were generally maintained on warfarin XARELTO patients were generally switched to warfarin without a period of coadministration of warfarin and XARELTO, so that they were not adequately anticoagulated after stopping XARELTO until attaining a therapeutic INR. Few patients in ROCKET AF underwent electrical cardioversion for atrial fibrillation. The utility of XARELTO for preventing post-cardioversion stroke and systemic embolism is unknown.
The management of atrial fibrillation (AFib) is not directly addressed in the provided drug label. However, it can be inferred that anticoagulation therapy, such as warfarin or XARELTO, may be used to prevent stroke or systemic embolism in patients with AFib.
- The label mentions that XARELTO was demonstrated to be non-inferior to warfarin for the primary composite endpoint of time to first occurrence of stroke (any type) or non-CNS systemic embolism.
- However, the label also states that the utility of XARELTO for preventing post-cardioversion stroke and systemic embolism is unknown. Therefore, a conservative clinical decision would be to consider anticoagulation therapy as a potential management option for AFib, but the specific details of management are not provided in the label 2.
From the Research
Management of Atrial Fibrillation (AFib)
The management of AFib involves two main tenets: prevention of stroke and systemic embolism, and symptom control with either a rate or a rhythm control strategy 3.
Rate Control Strategy
- Rate control strategy involves using rate-controlling agents such as beta-blockers, calcium channel blockers, or digoxin to control symptoms while allowing atrial fibrillation to persist 4, 5.
- The clinical target of rate control should be a ventricular rate below 80-90 bpm at rest 6.
- Beta-blockers or rate-limiting calcium antagonists are recommended as first-line treatment for rate control management in chronic atrial fibrillation 7.
Rhythm Control Strategy
- Rhythm control strategy involves cardioversion and treatment with antiarrhythmic drugs to maintain sinus rhythm 4.
- Newer data suggest that a rhythm control strategy with antiarrhythmic medications with or without catheter ablation may lead to a reduction in major adverse cardiovascular events, particularly in patients newly diagnosed with AF 3.
Choice of Treatment
- The choice of a rate control medication or a non-pharmacological approach must be based on clinical assessment, which includes assessing the presence of underlying heart disease and haemodynamic impairment 6.
- The combination of digoxin with either a beta-blocker or calcium antagonist should be considered as first-line management in patients with chronic atrial fibrillation 7.
Assessment of Efficacy
- Assessment of the appropriateness of different drugs should include exercise testing and 24h-Holter monitoring 6.
- Published studies are small and too heterogeneous to be quantitatively combined, and descriptive synthesis of the data shows little evidence that monotherapy with beta-blockers or calcium antagonists improves symptoms or exercise capacity in patients with chronic atrial fibrillation 7.