From the Guidelines
Medications to control atrial fibrillation should prioritize rate control with beta-blockers or calcium channel blockers, and anticoagulation with direct oral anticoagulants, as recommended by the most recent 2024 ESC guidelines 1. To control atrial fibrillation, the following medications can be used:
- For rate control:
- Beta-blockers like metoprolol (25-100 mg twice daily)
- Calcium channel blockers such as diltiazem (120-360 mg daily)
- Digoxin (0.125-0.25 mg daily) may be added for patients with heart failure
- For rhythm control:
- Antiarrhythmic medications like amiodarone (200 mg daily after loading), flecainide (50-200 mg twice daily), propafenone (150-300 mg three times daily), or sotalol (80-160 mg twice daily)
- Catheter ablation is a reasonable alternative for maintaining sinus rhythm, as recommended by the 2016 ESC guidelines 1 The choice between rate and rhythm control depends on symptom severity, age, other medical conditions, and patient preference, with rate control often preferred in older patients with fewer symptoms, and rhythm control benefiting younger patients with more severe symptoms, as suggested by the 2022 review on management of cardiac diseases in liver transplant recipients 1. Regular monitoring of heart rate, rhythm, and medication side effects is necessary, and dosages may need adjustment based on individual response and tolerance. Anticoagulation is essential regardless of the control strategy, with options including warfarin (target INR 2-3) or direct oral anticoagulants like apixaban (5 mg twice daily), rivaroxaban (20 mg daily), or dabigatran (150 mg twice daily), as recommended by the 2024 ESC guidelines 1.
From the FDA Drug Label
In patients without structural heart disease, propafenone is indicated to prolong the time to recurrence of – paroxysmal atrial fibrillation/flutter (PAF) associated with disabling symptoms. In patients without structural heart disease, flecainide acetate tablets, USP are indicated for the prevention of: •paroxysmal atrial fibrillation/flutter (PAF) associated with disabling symptoms The medications to control atrial fibrillation are:
- Propafenone (PO): indicated to prolong the time to recurrence of paroxysmal atrial fibrillation/flutter (PAF) associated with disabling symptoms 2
- Flecainide (PO): indicated for the prevention of paroxysmal atrial fibrillation/flutter (PAF) associated with disabling symptoms 3 Note that amiodarone (PO) is not specifically indicated for the control of atrial fibrillation, but rather for life-threatening ventricular arrhythmias 4
From the Research
Medications for Atrial Fibrillation Rate Control
- β blockers are effective in lowering the heart rate and are often used as a first-line treatment for rate control in atrial fibrillation 5, 6
- Non-dihydropyridine calcium-channel blockers can also be used to control the heart rate, but are not recommended for patients with heart failure 5, 6
- Digoxin is an option for rate control, particularly for physically inactive patients aged 80 years or older, but is generally considered less effective than β blockers and calcium-channel blockers 5, 7
- The choice of medication for rate control depends on the individual patient's symptoms and clinical characteristics 5, 8, 6
Alternative Treatment Options
- Atrioventricular node ablation with pacemaker insertion is a treatment option for rate control, but is typically used as a last resort 5, 8
- Catheter ablation of atrial fibrillation is also an option for patients who do not respond to medication or have severe symptoms 9, 6
- Rhythm control strategies, including antiarrhythmic medications and catheter ablation, may be considered for patients who do not respond to rate control or have severe symptoms 9, 6
Considerations for Treatment
- The goal of rate control is to reduce symptoms and prevent tachycardia-mediated cardiomyopathy 5, 7, 6
- Rate control is a top priority for all patients with atrial fibrillation, but the choice of treatment depends on individual patient characteristics and symptoms 5, 8, 6
- Regular assessment of heart rate and symptoms is necessary to adjust treatment as needed 7, 6