From the Guidelines
For a patient with fast atrial fibrillation (AFib) who remains tachycardic despite being on 1.25mg bisoprolol, I recommend increasing the bisoprolol dose gradually to achieve better rate control, as suggested by the 2024 ESC guidelines for the management of atrial fibrillation 1. The current dose is relatively low, and most patients require 5-10mg daily for effective rate control. Increase to 2.5mg daily for one week, then to 5mg daily if needed, monitoring for bradycardia, hypotension, or heart failure symptoms. According to the guidelines, rate control therapy should use beta-blockers (any ejection fraction), digoxin (any ejection fraction), or diltiazem/verapamil (LVEF >40%) as initial therapy in the acute setting, an adjunct to rhythm control therapies, or as a sole treatment strategy to control heart rate and symptoms 1. If the patient remains tachycardic despite reaching 10mg daily (maximum dose), consider adding a calcium channel blocker like diltiazem or verapamil, or digoxin as a second agent. Ensure the patient is adequately anticoagulated based on their CHA₂DS₂-VASc score to prevent stroke, as recommended by the guidelines, which state that oral anticoagulants are recommended for all eligible patients, except those at low risk of incident stroke or thromboembolism 1. Some key points to consider in the management of this patient include:
- Comorbidity and risk factor management, such as hypertension, heart failure, diabetes mellitus, obesity, obstructive sleep apnoea, physical inactivity, and high alcohol intake 1
- Assessment of the risk of thromboembolism using locally validated risk tools or the CHA2DS2-VA score 1
- Choice of anticoagulant, with DOACs (apixaban, dabigatran, edoxaban, and rivaroxaban) preferred over VKAs (warfarin and others), except in patients with mechanical heart valves and mitral stenosis 1
- Dose/range of anticoagulant, using full standard doses for DOACs unless the patient meets specific dose-reduction criteria 1 If rate control remains inadequate despite optimal medical therapy, rhythm control strategies including cardioversion or catheter ablation may be considered, with the primary indication being reduction in AF-related symptoms and improvement in quality of life 1.
From the Research
Current Treatment Options
The patient is currently on 1.25mg bisoprolol, which is a beta-blocker used for rate control in atrial fibrillation (AF) [ 2 ]. However, the patient still has a fast heart rate, indicating that the current treatment may not be sufficient.
Alternative Treatment Options
- Increasing the dose of bisoprolol may be considered to achieve better rate control [ 3 ].
- Adding a calcium channel blocker such as diltiazem or verapamil may also be an option to further reduce the heart rate [ 2 ].
- Digoxin can also be used for rate control, but its effectiveness may be limited in certain patients [ 4 ].
- Antiarrhythmic drugs such as amiodarone, sotalol, or flecainide can be used to restore sinus rhythm, but they have potentially serious adverse effects [ 2 ].
Non-Pharmacological Options
- Catheter ablation has shown promise in improving survival, quality of life, and ventricular function in patients with heart failure and reduced ejection fraction [ 5 ].
- Left atrial appendage closure may also be considered in certain patients to reduce the risk of stroke [ 5 ].
Considerations for Treatment
- The treatment approach should be individualized based on the patient's symptoms, underlying heart disease, and other factors [ 2 ].
- Anticoagulant or antiplatelet therapy should be considered to reduce the risk of stroke [ 2 ].
- The patient's response to treatment should be closely monitored, and adjustments made as needed to achieve optimal rate control and reduce symptoms [ 3 ].