From the Guidelines
Atrial fibrillation (Afib) treatment typically involves a combination of rate control and rhythm control strategies.
Rate Control
For rate control, beta blockers such as metoprolol (25-100mg twice daily) or calcium channel blockers like diltiazem (30-90mg three times daily) are commonly used 1.
- These medications are recommended as first-choice drugs in patients with AF and LVEF >40% to control heart rate and reduce symptoms.
- In patients with AF and LVEF ≤40%, beta-blockers and/or digoxin are recommended to control heart rate and reduce symptoms 1.
Rhythm Control
In cases where rhythm control is desired, anti-arrhythmic medications like amiodarone (400mg three times daily for 1-2 weeks, then 200mg daily) or flecainide (50-100mg twice daily) may be prescribed, often in conjunction with anticoagulation therapy such as apixaban (5mg twice daily) to reduce stroke risk 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.
Additional Considerations
- Anticoagulation therapy is recommended for all eligible patients, except those at low risk of incident stroke or thromboembolism (CHA2DS2-VA = 1) 1.
- Catheter ablation is a reasonable alternative to antiarrhythmic drug therapy for maintaining sinus rhythm, and is considered as a second-line option if antiarrhythmic drugs fail to control AF 1.
From the FDA Drug Label
14 CLINICAL STUDIES 14. 1 Reduction of Risk of Stroke and Systemic Embolism in Nonvalvular Atrial Fibrillation
ARISTOTLE Evidence for the efficacy and safety of apixaban was derived from ARISTOTLE, a multinational, double-blind study in patients with nonvalvular AF comparing the effects of apixaban and warfarin on the risk of stroke and non-central nervous system (CNS) systemic embolism.
The treatment options for Atrial Fibrillation (Afib) include:
- Anticoagulation therapy: Apixaban is effective in reducing the risk of stroke and systemic embolism in patients with nonvalvular Afib, and is superior to warfarin in this regard 2.
- Warfarin: Warfarin is also an option for stroke prevention in Afib, although it has a higher risk of major bleeding compared to apixaban 2.
Note: Flecainide may be used for rhythm control in patients with atrial fibrillation, but it is not recommended for patients with chronic atrial fibrillation due to the risk of ventricular pro-arrhythmic effects 3.
From the Research
Treatment Options for Atrial Fibrillation (Afib)
The treatment options for Atrial Fibrillation (Afib) can be broadly categorized into two main strategies: rate control and rhythm control.
- Rate control refers to the use of atrioventricular nodal blocking medications, including beta blockers and calcium channel blockers, to maintain a goal heart rate 4, 5, 6.
- Rhythm control, on the other hand, refers to a treatment strategy focused on the use of antiarrhythmic drugs (AAD), cardioversion, and ablation to restore and to maintain a patient in sinus rhythm 4, 5, 7.
Comparison of Rate and Rhythm Control Strategies
Several studies have compared the effectiveness of rate and rhythm control strategies in managing Afib.
- A randomized, multicenter comparison of these two treatment strategies in patients with Afib and a high risk of stroke or death found that management of Afib with the rhythm-control strategy offers no survival advantage over the rate-control strategy, and there are potential advantages, such as a lower risk of adverse drug effects, with the rate-control strategy 7.
- A meta-analysis of randomized controlled trials comparing rate and rhythm control strategies in patients with Afib found that a strategy of ventricular rate control, in combination with anticoagulation in appropriate patients, appears to be at least equivalent to a strategy of maintaining sinus rhythm by using currently available antiarrhythmic drugs in preventing clinical outcomes 8.
Anticoagulation Therapy
Anticoagulation therapy is an important aspect of Afib management, regardless of whether a rate or rhythm control strategy is employed.