What is the management of Atrial Fibrillation (AFIB) with bradycardia?

From the Guidelines

Atrial Fibrillation (AFIB) with bradycardia should be managed with a focus on rate control and rhythm control, while also considering anticoagulation therapy to prevent thromboembolism.

Key Management Strategies

• Rate control therapy is recommended as initial therapy in the acute setting, an adjunct to rhythm control therapies, or as a sole treatment strategy to control heart rate and reduce symptoms 1.
• Beta-blockers, diltiazem, verapamil, or digoxin are recommended as first-choice drugs in patients with AF and LVEF >40% to control heart rate and reduce symptoms 1.
• Beta-blockers and/or digoxin are recommended in patients with AF and LVEF ≤40% to control heart rate and reduce symptoms 1.
• Rhythm control therapy is indicated for symptom improvement in patients with AF, and entails electrical or pharmacological cardioversion of AF in symptomatic patients with persistent or longstanding-persistent AF, long-term antiarrhythmic drug therapy, catheter ablation, AF surgery, ablation, and pacing 1.
• Anticoagulation therapy is recommended for all eligible patients with AF, except those at low risk of incident stroke or thromboembolism, and should be based on the CHA2DS2-VA score and assessment of other risk factors 1.

Considerations for Bradycardia

• Avoid bradycardia when controlling heart rate in patients with AF, and aim for a lenient target heart rate (<110 beats/min at rest) 1.
• Monitor patients closely for signs of bradycardia, and adjust rate control therapy as needed to prevent bradycardia-related complications.

Additional Recommendations

• Assess the risk of thromboembolism using locally validated risk tools or the CHA2DS2-VA score, and reassess at periodic intervals to assist in decisions on anticoagulant prescription 1.
• Consider catheter ablation as a second-line option if antiarrhythmic drugs fail to control AF, or as a first-line option in patients with paroxysmal AF 1.

From the Research

Management of Atrial Fibrillation (AFIB) with Bradycardia

The management of atrial fibrillation (AFIB) with bradycardia involves several approaches, including:

• Rate control, which is central to AFIB management, even for patients who ultimately require control of the rhythm 2
• Choice of rate control depends on the symptoms and clinical characteristics of the patient, with β blockers, alone or in combination with digoxin, or non-dihydropyridine calcium-channel blockers being effective options 2
• Digoxin is least effective, but a reasonable choice for physically inactive patients aged 80 years or older, in whom other treatments are ineffective or are contraindicated, and as an additional drug to other rate-controlling drugs, especially in heart failure when instituted cautiously 2
• Atrioventricular node ablation with pacemaker insertion for rate control should be used as an approach of last resort but is also an option early in the management of patients with AFIB treated with cardiac resynchronisation therapy 2

Bradycardia-Related Considerations

Bradycardia could facilitate the emergence of AFIB, and the development of bradycardia-induced ventricular tachyarrhythmias (VAs) could be fatal if there is no prompt intervention 3

• Bradycardia-related cardiomyopathy and heart failure, as well as an adverse influence on brain function, may all be eluding consequences of this type of syndrome 3
• Balancing the benefits and risks of bradycardia together with other risks of antiarrhythmic drug and/or pacing management of AFIB versus those of catheter ablation is indeed a vexing problem 3

Treatment Options

Current therapy for AFIB mainly includes:

• Drug therapy 4
• Catheter ablation 4
• Cryoballoon ablation 4
• Left atrial appendage closure 4
• The maze procedure 4
• β-blocker treatment, which may be limited by dose-limiting, adverse event-associated bradycardia 5

Evaluation and Management of Bradycardia

Bradycardia is a commonly observed arrhythmia and a frequent occasion for cardiac consultation, and treatment should rarely be prescribed solely on the basis of a heart rate lower than an arbitrary cutoff or a pause above certain duration 6

• Assessment of symptoms is a critical component in the evaluation and management of bradycardia 6
• The 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients with Bradycardia and Cardiac Conduction Delay emphasizes the importance of evaluation and management of disease states rather than device-based implantation recommendations 6