What is the plan for a patient on metoprolol (beta blocker) with uncontrolled atrial fibrillation (AFib) flutter, who is also taking Eliquis (apixaban) and remains in atrial flutter?

From the Guidelines

For a patient with uncontrolled atrial fibrillation/flutter who is already on metoprolol and Eliquis, I strongly recommend optimizing the metoprolol dose to achieve better rate control, as beta-blockers are recommended as first-choice drugs for heart rate control in patients with AF and LVEF >40% 1. The patient's current uncontrolled AFib/flutter suggests that the metoprolol dose may need to be adjusted to achieve a heart rate below 100 beats per minute. Key considerations for the plan include:

• Evaluating the patient's left ventricular ejection fraction (LVEF) to determine the best approach for heart rate control, as beta-blockers and/or digoxin are recommended for patients with AF and LVEF ≤40% 1
• Continuing Eliquis for stroke prevention, as the patient is already on this medication and it is essential for reducing stroke risk in patients with AFib/flutter
• Assessing for potential triggers such as thyroid dysfunction, sleep apnea, excessive alcohol consumption, or electrolyte abnormalities, and addressing them as needed
• Considering rhythm control strategies, including electrical cardioversion or adding an antiarrhythmic medication, depending on the patient's cardiac structure and comorbidities
• Referral to electrophysiology for catheter ablation may be appropriate if the patient has been in AFib/flutter for an extended period or has failed previous rhythm control attempts. Regular follow-up with ECG monitoring is essential to evaluate treatment effectiveness and adjust the plan as needed.

From the Research

Patient's Current Situation

• The patient is currently on metoprolol and has been experiencing atrial fibrillation (AFib) with an uncontrolled rate.
• The patient has also been taking Eliquis, an anticoagulant medication.
• Despite the current treatment, the patient is still experiencing AFib flutter.

Treatment Options for AFib

• According to 2, the treatment aims for AFib are to reduce symptoms, prevent embolism, and prevent deterioration of underlying heart disease.
• The study suggests that rate control is often better than rhythm control, and that digoxin, beta-blockers, diltiazem, and verapamil can be used to slow the heart rate.
• 3 and 4 compared the effectiveness of intravenous diltiazem, metoprolol, and verapamil for rate control in patients with AFib, and found that any of these agents can be used for rate control.

Comparison of Metoprolol and Diltiazem

• 5 found that metoprolol was associated with a 26% lower risk of adverse events compared to diltiazem, with a total incidence of 10% for metoprolol and 19% for diltiazem.
• However, 4 found no difference in sustained rate control between metoprolol and diltiazem, with 87.5% of patients in the diltiazem group and 78.9% of patients in the metoprolol group achieving sustained rate control.

Potential Next Steps

• Considering the patient's current situation, the healthcare provider may choose to continue with the current treatment plan or adjust the medication regimen to better control the patient's heart rate.
• The provider may also consider alternative treatment options, such as electrical cardioversion or antiarrhythmic therapy, as suggested by 2.
• It is essential to monitor the patient's condition closely and adjust the treatment plan as needed to ensure optimal outcomes.