From the Guidelines
The treatment for acute atrial fibrillation (AFib) should focus on controlling heart rate and preventing complications, with rate control medications such as beta-blockers, diltiazem, verapamil, or digoxin being recommended as first-choice drugs to control heart rate and reduce symptoms 1.
Key Considerations
- The initial management of AFib includes rate control medications to slow the ventricular heart rate and reduce symptoms.
- Beta-blockers, such as metoprolol, and calcium channel blockers, such as diltiazem, are commonly used for rate control.
- Digoxin may also be used, especially in patients with left ventricular ejection fraction (LVEF) ≤40% 1.
Rhythm Control and Anticoagulation
- Rhythm control therapies, such as antiarrhythmic drugs or electrical cardioversion, may be considered in hemodynamically stable patients with symptomatic AFib.
- Anticoagulation should be started immediately with heparin, enoxaparin, or direct oral anticoagulants to prevent stroke, especially if AFib has lasted more than 48 hours.
- The CHADS-VASc score should be used to evaluate stroke risk and guide anticoagulation therapy 1.
Underlying Cause and Treatment
- The underlying cause of AFib should be identified and treated, which may include addressing electrolyte imbalances, thyroid disorders, or infection.
- A lenient target heart rate (<110 beats/min at rest) should be initially aimed for, with a lower heart rate attempted if symptoms persist, while avoiding bradycardia 1.
Recommendations
- Beta-blockers, diltiazem, verapamil, or digoxin are recommended as first-choice drugs to control heart rate and reduce symptoms in patients with AFib and LVEF >40% 1.
- Beta-blockers and/or digoxin are recommended in patients with AFib and LVEF ≤40% to control heart rate and reduce symptoms 1.
- Anticoagulation should be initiated in all patients with documented AFib who have an increased risk of stroke, based on the CHADS-VASc score 1.
From the Research
Treatment Options for Acute Atrial Fibrillation
The treatment for acute atrial fibrillation (AFib) typically involves rate control or rhythm control strategies.
- Rate control is often achieved using intravenous (IV) non-dihydropyridine calcium channel blockers (CCB) or beta blockers (BB) 2.
- The choice between beta blockers and calcium channel blockers depends on various factors, including patient characteristics and hospital preferences 3.
Comparison of Beta Blockers and Calcium Channel Blockers
Studies have compared the efficacy of beta blockers and calcium channel blockers in achieving rate control in patients with AFib.
- A study found that beta blockers were more effective in reducing heart rate and shortening hospitalization duration compared to calcium channel blockers 4.
- Another study found that calcium channel blockers were used more frequently for rate control than beta blockers, and complications were rare and easily managed using both agents 3.
Considerations for Patients with Heart Failure
For patients with concomitant heart failure with reduced ejection fraction (HFrEF), the American Heart Association recommends avoiding calcium channel blockers due to their potential negative inotropic effects 2.
- However, a study found that the incidence of adverse effects, including worsening heart failure symptoms, was similar between patients treated with IV diltiazem (a calcium channel blocker) and metoprolol (a beta blocker) 2.
Other Treatment Options
Other treatment options for AFib include:
- Catheter ablation, which is an effective non-pharmacological alternative for achieving rhythm control 5, 6.
- Left atrial appendage closure and the maze procedure, which are also used to treat AFib 5.
- Antiarrhythmic drugs, which can be used to maintain sinus rhythm, but the choice of drug depends on safety and efficacy considerations 6.