From the Guidelines
When starting rate-lowering therapy, it is crucial to choose the right medication based on the patient's left ventricular ejection fraction (LVEF) to control heart rate and reduce symptoms, with beta-blockers, diltiazem, verapamil, or digoxin recommended as first-choice drugs in patients with AF and LVEF >40% 1. The selection of the appropriate medication is vital to achieve optimal outcomes in terms of morbidity, mortality, and quality of life.
- Key considerations include:
- The patient's LVEF, as this guides the choice between different medications
- The presence of symptoms, as this influences the need for rate control therapy
- The potential for haemodynamic instability or severely depressed LVEF, which may require intravenous medications such as amiodarone, digoxin, esmolol, or landiolol 1
- The recommended first-choice drugs for patients with AF and LVEF >40% are:
- Beta-blockers
- Diltiazem
- Verapamil
- Digoxin
- For patients with AF and LVEF ≤40%, beta-blockers and/or digoxin are recommended 1
- It is also important to consider the potential need for combination rate control therapy if a single drug does not control symptoms or heart rate, as well as the option for atrioventricular node ablation combined with cardiac resynchronization therapy in severely symptomatic patients with permanent AF and at least one hospitalization for heart failure 1.
From the FDA Drug Label
The study thus was able to show a benefit from the overall metoprolol regimen but cannot separate the benefit of very early intravenous treatment from the benefit of later beta-blocker therapy Nonetheless, because the overall regimen showed a clear beneficial effect on survival without evidence of an early adverse effect on survival, one acceptable dosage regimen is the precise regimen used in the trial Because the specific benefit of very early treatment remains to be defined however, it is also reasonable to administer the drug orally to patients at a later time as is recommended for certain other beta-blockers.
When starting rate-lowering therapy (heart rate lowering), timing of treatment is important. It is reasonable to administer the drug orally to patients at a later time, as is recommended for certain other beta-blockers 2. The overall regimen should show a clear beneficial effect on survival without evidence of an early adverse effect on survival.
- Early treatment may be beneficial, but its specific benefit remains to be defined.
- Later beta-blocker therapy may also be effective. It is essential to carefully evaluate the patient's clinical condition and hemodynamic status before initiating therapy 2.
From the Research
Important Considerations for Rate-Lowering Therapy
When starting rate-lowering therapy, several factors are important to consider:
- The type of medication used, with calcium channel blockers and beta-blockers being common options 3, 4, 5, 6, 7
- The efficacy of the medication in reducing heart rate and improving symptoms 3, 4, 5, 6, 7
- The potential side effects of the medication, such as bradycardia or hypotension 3, 4, 5, 6, 7
- The individual patient's characteristics, such as age, sex, and comorbidities 5, 6, 7
Medication Options
The choice of medication for rate-lowering therapy depends on various factors, including:
- Calcium channel blockers, such as diltiazem and verapamil, which have been shown to be effective in reducing heart rate and improving symptoms 3, 4, 6, 7
- Beta-blockers, such as metoprolol and carvedilol, which have also been shown to be effective in reducing heart rate, but may have more side effects 3, 4, 5, 6, 7
Patient Characteristics
Patient characteristics, such as age and comorbidities, can influence the choice of medication and the efficacy of rate-lowering therapy: