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Literature review current through: Jan 2024. | This topic last updated: Nov 09, 2023.
INTRODUCTION
In patients with atrial fibrillation (AF), the ventricular rate is modulated by the
conduction properties of the atrioventricular (AV) node. In the typical patient with
untreated AF, the ventricular rate can reach 150 beats/min or higher.
Further information regarding the overall management of patients with AF, including
anticoagulation and choice of rhythm versus rate control, is discussed separately:
Atrial fibrillation — During AF, electrical activity in the atria can exceed 400
beats/min. The majority of these impulses do not conduct to the ventricles because of
the electrophysiologic properties of the AV node. (See "Mechanisms of atrial
fibrillation", section on 'Role of the atrioventricular node'.)
The relatively slow kinetics of the inward calcium current limit conduction velocity
through the AV node, and therefore the ventricular rate during AF. In addition to
these intrinsic properties, the AV node is also richly supplied and affected by both
components of the autonomic nervous system. AV conduction is enhanced by
sympathetic fibers and slowed by parasympathetic fibers ( figure 1).
In the typical patient with untreated AF, the ventricular rate during the day varies
between 90 and 170 beats/min. The ventricular rate may be slower (eg, less than 60
beats/min) in the following settings:
A ventricular rate above 200 beats/min suggests one or more of the following:
● Catecholamine excess
● Enhanced AV nodal conduction
● Parasympathetic withdrawal
● Hyperthyroidism
● An accessory pathway as occurs in the preexcitation syndrome (see
"Atrioventricular reentrant tachycardia (AVRT) associated with an accessory
pathway")
Specific reasons for slowing the ventricular rate in patients with AF include the
following:
● Hemodynamic instability – This may be acute and may require urgent therapy.
This is discussed in detail separately. (See "Hemodynamic consequences of atrial
fibrillation and cardioversion to sinus rhythm".)
● Symptoms – Patients with AF may or may not have associated symptoms, and
the spectrum of symptoms is broad. Typical symptoms include palpitations,
tachycardia, fatigue, weakness, dizziness, lightheadedness, reduced exercise
capacity, increased urination, or mild dyspnea. Symptoms of AF are discussed in
detail separately. (See "Atrial fibrillation: Overview and management of new-onset
atrial fibrillation", section on 'Symptoms'.)
● Spontaneous conversion to sinus rhythm – Some patients whose rate has been
slowed and who then tolerate AF may spontaneously convert to normal sinus
rhythm without the need for electrical cardioversion. Spontaneous conversion is
most likely to occur in patients with a duration of AF of less than 48 hours, or in
patients with a history of short, self-limited episodes [3]. The rate of spontaneous
conversion has been reported to be around 50 percent at 48 hours [3]. In a
retrospective study of 438 patients with AF, if the AF onset was <48 hours,
spontaneous conversion occurred in 77 percent compared with 36 percent in the
group with first onset AF >48 hours [4]. In a separate study of 943 patients,
spontaneous conversion was shown to occur most frequently in patients with
first-onset AF <24 hours, a lower body mass index, and normal left atrial size [5].
EVALUATION AND GOAL VENTRICULAR RATE
● Evaluation and monitoring of ventricular rate – In practice, the ventricular rate
can be assessed by measurement of both the resting ventricular rate and use of
one of the following to assess exercise:
These methods of assessing ventricular rate can be used both at the start of therapy
and for long-term follow-up.
In the subset of patients with AF who are asymptomatic and have permanent AF,
a less strict rate control goal of <110 beats/min may be reasonable. These
patients should be monitored for the development of tachycardia-mediated
cardiomyopathy. (See "Arrhythmia-induced cardiomyopathy".)
Alternative goal rates that are similar to those recommended for patients in sinus
rhythm with heart disease can also be used: resting heart rate ≤80 beats/min and
≤110 beats/min during moderate exercise such as with the six-minute walk. Goals
similar to these were used in many of the trials of rate versus rhythm control,
such as AFFIRM [8]. The AFFIRM study is discussed in detail separately. (See
"Management of atrial fibrillation: Rhythm control versus rate control", section on
'High cardiovascular risk'.)
Thus, for those patients in whom a lenient strategy is chosen but who remain
symptomatic, an attempt should be made to decrease symptoms by setting a
lower rate goal. A more lenient rate-control strategy offers the advantages of less
medication (fewer drug side effects, lower cost) and fewer outpatient visits to
achieve ventricular rate control.
The recommended goal rate is based on the observation that 85 beats/min was
the mean achieved rate for patients assigned lenient rate control in the RACE
study [9]. In this trial of patients with permanent AF, adhering to a strict rather
than lenient rate-control strategy did not improve cardiovascular or safety
outcomes. This study also supports our practice in which achieving strict rate
control is not necessary in many physically active patients with AF who are
minimally symptomatic. In the RACE study, 614 physically active patients with
permanent AF were randomly assigned either lenient rate control (resting heart
rate <110 beats/min) or a strict rate control (resting heart rate <80 beats/min and
heart rate during moderate exercise <110 beats per minute). Patients were
followed for the primary outcome of cardiovascular death, hospitalization for
heart failure, stroke, systemic embolism, bleeding, and life-threatening
arrhythmic events. The following findings were noted:
• Similar efficacy of lenient and strict rate control – After three years, the
estimated cumulative incidence of the primary outcome was similar in both
groups (12.9 versus 14.9 percent, respectively; hazard ratio [HR] 0.84; 90% CI
0.58-1.21).
• Fewer people in strict versus lenient group met heart rate target – The
percentage of patients was 98 and 75 percent, respectively [10].
• More medical visits in strict rate-control group – There were nearly nine
times as many visits (684 versus 75) to achieve rate control target(s) in the
strict control.
• Low resting heart rates were achieved in the lenient group too – In
patients assigned to lenient rate control, the mean resting rates at the end of
follow-up was 85+14 beats/min compared with 76+14 beats/min in those
assigned to strict control.
The results of the RACE trial must be tempered given that the lenient-control
group was in fact treated more aggressively than the protocol required. In
addition, RACE included only patients with permanent AF, so the results are not
generalizable to those with paroxysmal or persistent AF.
INITIAL CONSIDERATIONS
The initial management of patients with AF and a rapid ventricular response involves
the following:
Deciding on rate control — The advantages and disadvantages of rhythm and rate
control, as well as whether there are subgroups of patients for whom one or the other
should be preferred, are discussed separately. (See "Management of atrial fibrillation:
Rhythm control versus rate control".)
URGENT THERAPY
This section describes our approach to urgent ventricular rate control in patients with
AF who do not have heart failure ( algorithm 1). Rate control of patients who have
AF and heart failure is discussed separately. (See "The management of atrial
fibrillation in patients with heart failure", section on 'Acute decompensation'.)
Choice of initial urgent therapy — Patients who require urgent therapy need to be
in a monitored setting. In patients without symptomatic hypotension (eg, in those
with ischemia without hypotension), we select diltiazem as the initial agent.
Intravenous (IV) esmolol, verapamil, or other IV beta blockers such as metoprolol are
reasonable alternatives to diltiazem. If it is uncertain whether the patient will become
hypotensive with a beta blocker, we use esmolol since this medication has a very
short half-life and can be immediately discontinued if needed. (See 'Hypotensive
patient' below.)
In the absence of larger randomized trials, much of the current management relies
on clinical experience rather than evidence. Diltiazem may have a less pronounced
negative inotropic effect than verapamil [11]. The IV preparation is convenient and
effective for acute control of the ventricular rate in AF [12-14], while oral therapy is
effective for chronic rate control [15,16]. In our experience, either a beta blocker or
calcium channel blocker could result in hypotension, and therefore careful blood
pressure monitoring is needed regardless of the choice of medication. Small,
heterogenous studies of urgent control of ventricular rate in AF suggest higher
efficacy for IV diltiazem versus IV beta blocker therapy:
● One meta-analysis of three studies including 160 patients and comparing effects
of IV diltiazem versus IV metoprolol showed an average of 9 mm lower systolic
blood pressure with metoprolol at 15 minutes following treatment but no
differences at earlier or later timepoints (ie 5, 10, or 30 minutes) [17].
The suggested regimen for IV diltiazem is derived from the Diltiazem Atrial
Fibrillation/Atrial Flutter Study Group [12-14]. The efficacy of this regimen was
evaluated in a report of 84 consecutive patients with AF, atrial flutter, or both [14]. The
overall response rate was 94 percent. The continuous infusion maintained adequate
rate control for 10 hours or longer in a dose-dependent fashion: 47 percent at 5
mg/hour; 68 percent after titration to 10 mg/hour; and 76 percent after titration to 15
mg/hour ( figure 3). Hypotension occurred in 13 percent and was symptomatic in
almost 4 percent. All such patients responded to an infusion of normal saline. Weight-
based dosing of IV diltiazem is further supported in a study of 252 patients who
received IV diltiazem for acute rate control in the emergency department. Weight-
based dosing (0.25 mg/kg) was associated with higher rates of rate control without
increased adverse effects [18].
Hypotensive patient
Asymptomatic and not on a vasopressor — If the patient is mildly hypotensive but
asymptomatic and does not require a vasopressor, we typically start metoprolol
tartrate (short-acting) 25 mg by mouth every six hours and up-titrate as needed and
as tolerated by 12.5 mg every six hours until the rate is controlled. Other IV beta
blockers and calcium channel blockers may cause worsening hypotension.
If none of these therapies work, we typically opt for acute cardioversion rather
than continued attempts at rate control (with evaluation of the left atrial
appendage thrombus if warranted and clinically feasible and appropriate
anticoagulation strategy).
Ivabradine blocks the pacemaker current, which is primarily thought to affect the
sinoatrial node; however, some studies have shown that this current is also expressed
in the atrioventricular node. Accordingly, a few studies are investigating the use of
ivabradine for ventricular rate control in AF. One retrospective study of 18 patients
with permanent AF showed average reduction in ventricular rate from 104.6 to 89
[21]. The BRAKE-AF trial randomized patients with permanent AF to ivabradine or
digoxin. Ivabradine was found to reduce the average ventricular rate by an average of
11.6 beats/minute, which was significantly less than the reduction observed with
digoxin (19.6 beats/minute). Though the number of serious adverse events were
similar in each group, ivabradine was better tolerated and had a higher compliance
through the study [22]. At present, there is insufficient evidence to recommend the
routine use of ivabradine for ventricular rate control in AF; it can be used if more
commonly used rate control agents are unsuccessful or not tolerated [23].
When transitioning from IV to oral medications, we generally convert the total daily
dose of the IV medication to an equivalent divided or long-acting oral dose of a
medication in the same class. We often use pharmacy or pharmacist-based reference
for appropriate conversion dosages. For example, if a patient is placed on IV
diltiazem, we will usually convert the patient to a short or long-acting oral formulation
of diltiazem that gives an equivalent daily dose of the medication. A general formula
for approximate conversion from IV diltiazem to the daily oral dose is [(infusion rate
x3)+3]x10 [24]. Example conversions from IV to oral dosing for diltiazem and
metoprolol are shown in a table ( table 2). Other nuances of long-term rate control
medications are discussed separately. (See 'Elective and long-term management'
below.)
Choice of nonurgent therapy — Although there are differences in the efficacy of the
various drugs, it is likely that monitoring and adjustments to therapy are more
important components of successful rate-control strategies than the initial drug
selection. Studies of specific pharmacologic agents for management of AF are small
and heterogeneous.
● Both beta blockers and calcium channel blockers were effective – Diltiazem,
verapamil, and most beta blockers (atenolol, metoprolol, timolol, pindolol, and
nadolol) were all effective in reducing the ventricular rate during rest and
exercise. The beta blockers labetalol, xamoterol, and celiprolol were less effective
at rest but did reduce ventricular rates during exercise.
● Mixed results for digoxin versus placebo – Trials comparing digoxin with
placebo reported inconsistent results, particularly when heart rate during
exercise was assessed.
● Digoxin was effective when added to beta blocker or calcium channel blocker
– The combination of digoxin with a beta blocker or calcium channel blocker
reduced heart rate both at rest and with exertion.
● AFFIRM trial – Among evaluations of rate-control drugs, the study with the
largest sample size and longest follow-up is a post-hoc analysis from the AFFIRM
trial [27]. The original AFFIRM trial assigned patients with AF to either rate or
rhythm control, and a post-hoc analysis compared the efficacy of various rate-
control medications. In this post-hoc study, over 2000 patients assigned to rate
control were given medications according to physician preference. Effectiveness
of rate control was defined as a resting heart rate ≤80 beats/minute, exertional
heart rate ≤110 beats/min during six-minute walk test or average heart rate
during 24-hour ambulatory Holter monitoring ECG ≤100 beats/min (at least 18
hours of interpretable monitoring), and no heart rate >110 percent maximum
predicted age-adjusted exercise heart rate.
The overall effectiveness (meeting both rest and exertion heart rate goals) of
initial monotherapy therapy was most effective for beta blockers (59 percent),
followed by digoxin (58 percent), and then calcium channel blockers (38 percent).
Oral beta blockers are widely used as primary therapy for rate control in chronic
AF. Beta blockers decrease the resting ventricular rate and blunt the ventricular
rate response to exercise. Most beta blockers appear to have similar efficacy. For
patients with heart failure with systolic dysfunction, the preferred agents for
treatment are metoprolol succinate, carvedilol, carvedilol continuous release,
and bisoprolol. (See "Primary pharmacologic therapy for heart failure with
reduced ejection fraction", section on 'Beta blocker'.)
In a post-hoc analysis of the AFFIRM trial of rate versus rhythm control in patients
with AF, beta-blocker therapy was shown to be effective in achieving goal
ventricular rate in 59 percent of people [27]. The AFFIRM trial is discussed in
greater detail separately. (See 'Choice of nonurgent therapy' above.)
There is the most supporting evidence for metoprolol, atenolol, and nadolol.
Atenolol and nadolol have the advantages of a long half-life and are typically
given once daily. Long-acting propranolol can be effective. Bisoprolol and
carvedilol are also used ( table 2).
Beta blockers have additional properties that may make them preferred to other
rate-control drugs in some AF patients:
Some patients with paroxysmal AF also have sinus node dysfunction, with
tachycardia-bradycardia syndrome. In such patients, beta blockers with intrinsic
sympathomimetic activity may be useful since they are less likely to worsen
bradycardia than standard beta blockers. (See "Sinus node dysfunction:
Epidemiology, etiology, and natural history".)
In a post-hoc analysis of the AFFIRM trial of rate versus rhythm control in patients
with AF, calcium channel blocker therapy was shown to be effective in achieving
goal ventricular rate in 38 percent of people [27]. The AFFIRM trial is discussed in
greater detail separately. (See 'Choice of nonurgent therapy' above.)
In summary, diltiazem and verapamil should not be given to patients with severe
heart failure (New York Heart Failure class III or IV), preexcitation syndrome, or
significant hypotension. In addition, these drugs should be given with caution to
patients with sinus node dysfunction, significant liver disease, mild hypotension,
marked first-degree heart block, or the concurrent intake of other drugs that
inhibit SA nodal function or slow AV nodal conduction. Considerations for patients
with heart failure are discussed separately. (See "The management of atrial
fibrillation in patients with heart failure", section on 'Rate control in heart failure
with reduced ejection fraction' and "The management of atrial fibrillation in
patients with heart failure", section on 'Rate control in heart failure with
preserved ejection fraction'.)
Combination therapy
The AFFIRM trial is discussed in greater detail separately. (See 'Choice of nonurgent
therapy' above.)
In patients with AF, the following summarizes evidence regarding the efficacy and
safety of digoxin as a combination drug for rate control:
• Three large observational studies of digoxin use among patients with AF have
yielded mixed results, with at least two finding an increase in all-cause
mortality of about 20 percent [30,31] and one finding no increase [32].
• The best available evidence regarding the relationship between digoxin use in
AF patients (either alone or in combination with a beta blocker or calcium
channel blocker) and mortality comes from a post-hoc subgroup analysis of the
ARISTOTLE trial of anticoagulant therapy [33]. The following findings were
reported:
- Baseline digoxin use was not associated with an increased risk of death
(adjusted hazard ratio [HR] 1.09; 95% CI 0.96-1.23)
- Digoxin concentration ≥1.2 ng/mL was associated with an increased risk of
death (adjusted HR 1.56; 95% CI 1.20-2.04)
- New digoxin use was associated with a higher risk of death (adjusted HR
1.78; 95% CI 1.37-2.31)
- Having heart failure versus not having heart failure did not change these
effects.
The use of digoxin in patients with AF and heart failure is discussed separately.
(See "The management of atrial fibrillation in patients with heart failure", section
on 'Rate control in heart failure with reduced ejection fraction'.)
Alternative medications
● Amiodarone – For patients with AF, there is a limited role for amiodarone as a
long-term agent for rate control. Due to the increased risk of side effects, the
2014 American Heart Association/American College of Cardiology/Heart Rhythm
Society AF guideline states that amiodarone can be used as second-line therapy
for chronic rate control only when other therapies are unsuccessful or
contraindicated [34,35]. We agree with this guideline, and for patients treated
with amiodarone for long-term rate control of AF, we require careful follow-up,
including monitoring for known medication side effects. (See "Amiodarone:
Adverse effects, potential toxicities, and approach to monitoring".)
Data supporting the use of amiodarone as a rate-control agent for AF are more
limited compared with evidence supporting its use for pharmacologic rhythm
control of AF. In one study, IV amiodarone (7 mg/kg), flecainide, or placebo were
given to 98 patients with recent-onset AF (0.5 to 72 hours) [36]. Even when AF did
not revert to sinus rhythm, amiodarone promptly slowed the ventricular rate
during the eight-hour observation period ( figure 4). In addition, in critically ill
patients, amiodarone may be less likely to cause systemic hypotension than IV
diltiazem [37].
• It may not be appropriate for use in older patients. There are additional
reasons that digoxin should not be used as an initial drug for rate control in
most settings.
• Generally less effective rate control compared with beta blockers or calcium
channel blockers, particularly during exercise when vagal tone is low and
sympathetic tone is high [38]. This is because the drug slows the ventricular
rate during AF, primarily by vagotonic inhibition of AV nodal conduction.
One study suggests that digoxin may have a similar efficacy for rate control as
bisoprolol [39]. However, the higher toxicity profile and risk of mortality prevent
us from using it as monotherapy.
UpToDate offers two types of patient education materials, “The Basics” and “Beyond
the Basics.” The Basics patient education pieces are written in plain language, at the
5th to 6th grade reading level, and they answer the four or five key questions a patient
might have about a given condition. These articles are best for patients who want a
general overview and who prefer short, easy-to-read materials. Beyond the Basics
patient education pieces are longer, more sophisticated, and more detailed. These
articles are written at the 10th to 12th grade reading level and are best for patients
who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage
you to print or e-mail these topics to your patients. (You can also locate patient
education articles on a variety of subjects by searching on “patient info” and the
keyword(s) of interest.)
● Basics topic (see "Patient education: Medicines for atrial fibrillation (The Basics)")
● Beyond the Basics topic (See "Patient education: Atrial fibrillation (Beyond the
Basics)".)
● Urgent therapy
ACKNOWLEDGMENT
The UpToDate editorial staff acknowledges Leonard Ganz, MD, FHRS, FACC, who
contributed to an earlier version of this topic review.
REFERENCES