From the Guidelines
Atrial fibrillation management should prioritize the AF-CARE pathway, which includes comorbidity and risk factor management, avoiding stroke and thromboembolism, reducing symptoms by rate and rhythm control, and evaluation and dynamic reassessment, as recommended by the 2024 ESC guidelines 1. The optimal treatment approach involves a multidisciplinary team and patient-centered care, with a focus on shared decision-making and education for patients, family members, caregivers, and healthcare professionals. Key aspects of management include:
- Diagnosis confirmation on an ECG device to initiate risk stratification and AF management
- Initial evaluation of medical history, symptoms, blood tests, echocardiography, and risk factors for thromboembolism and bleeding
- Comorbidity and risk factor management, including conditions associated with AF such as hypertension, heart failure, diabetes mellitus, obesity, obstructive sleep apnea, physical inactivity, and high alcohol intake
- Assessing the risk of thromboembolism using locally validated risk tools or the CHA2DS2-VA score, with reassessment at periodic intervals to guide anticoagulant prescription
- Oral anticoagulants, such as direct oral anticoagulants (DOACs), are recommended for all eligible patients, except those at low risk of incident stroke or thromboembolism, with a preference for DOACs over vitamin K antagonists (VKAs) unless specific criteria are met 1. Rate control therapy may involve beta-blockers, digoxin, or diltiazem/verapamil, while rhythm control may be considered in suitable patients, with options including cardioversion, antiarrhythmic drugs, and catheter or surgical ablation, always keeping safety and anticoagulation in mind 1. Lifestyle modifications, such as reducing alcohol intake, managing sleep apnea, controlling blood pressure, and maintaining a healthy weight, are also crucial in managing atrial fibrillation. The primary indication for long-term rhythm control should be the reduction in AF-related symptoms and improvement in quality of life, with sinus rhythm maintenance pursued in selected patient groups to reduce morbidity and mortality 1.
From the FDA Drug Label
Sotalol AF are indicated for the maintenance of normal sinus rhythm [delay in time to recurrence of atrial fibrillation/atrial flutter (AFIB/AFL)] in patients with symptomatic AFIB/AFL who are currently in sinus rhythm. Patients with atrial fibrillation should be anticoagulated according to usual medical practice.
Atrial Fibrillation Treatment: Sotalol AF is indicated for the maintenance of normal sinus rhythm in patients with symptomatic atrial fibrillation/atrial flutter (AFIB/AFL) who are currently in sinus rhythm 2.
- Key Points:
- Sotalol AF should be reserved for patients in whom AFIB/AFL is highly symptomatic.
- Patients with atrial fibrillation should be anticoagulated according to usual medical practice 2.
From the Research
Atrial Fibrillation Overview
- Atrial fibrillation (AF) is a common dysrhythmia associated with significant morbidity and mortality 3
- It can present with a rapid ventricular response (RVR), requiring rate control to lower the heart rate 3
Rate Control Options
- Calcium channel blockers (e.g., diltiazem, verapamil) and beta-blockers (e.g., metoprolol, carvedilol) are commonly used for rate control in AF 3, 4
- Diltiazem and verapamil have been shown to reduce heart rate and improve exercise tolerance in patients with AF 4, 5
- Beta-blockers, such as metoprolol and carvedilol, can also control heart rate, but may reduce exercise capacity and increase NT-proBNP levels 5
Comparison of Rate Control Agents
- Diltiazem may achieve rate control faster than metoprolol, although both agents are safe and effective 3
- Verapamil and diltiazem have been shown to be efficacious for heart rate control at rest and during exercise, with equivalent or improved exercise tolerance 4
- Beta-blockers, such as nadolol and atenolol, have also been found to be efficacious for control of resting heart rate, with good heart rate control during exercise 4
Patient-Specific Factors
- Patient-specific factors, such as prior medication use, hemodynamic and clinical characteristics, can influence the choice of rate control agent 6
- A history of AF, diabetes mellitus, or prior beta-blocker use may predict the selection of metoprolol over diltiazem for rate control 6
Special Considerations
- In patients with heart failure with reduced ejection fraction (HFrEF), calcium channel blockers may be avoided due to their potential negative inotropic effects 7
- However, a study found no difference in total adverse events between diltiazem and metoprolol in HFrEF patients with AF, although diltiazem was associated with a higher incidence of worsening heart failure symptoms 7