EKG
Atrial Fibrillation Rate Control
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Atrial Fibrillation Rate Control
, Atrial Flutter Rate Control
See Also
Atrial Fibrillation
Atrial Flutter
Atrial Fibrillation Causes
Electrocardiogram in Atrial Fibrillation
Atrial Fibrillation Acute Management
Atrial Fibrillation Anticoagulation
Electrical Synchronized Cardioversion of Atrial Fibrillation
Synchronized Cardioversion
Atrial Fibrillation Rhythm Control
(and
Atrial Fibrillation Chemical Cardioversion
)
Indications
Chronic control
Age over 65 years
Coronary Artery Disease
Contraindications to
Antiarrhythmic
medications
Cardioversion unlikely to be effective (e.g. atrial enlargement)
Acute episode
Atrial Fibrillation with Rapid Ventricular Rate
Precautions
Beware agents (e.g.
Amiodarone
) which may cardiovert
Atrial Fibrillation
>48 hours
Risk of embolic complications
Exam
Target
Heart Rate
Heart Rate
with
Exercise
: <110 bpm
Heart Rate
at rest: <80 bpm
Heart Rate
s up to 110 at rest may be acceptable for asymptomatic patients
Van Gelder (2010) N Engl J Med 362(15):1363-73 +PMID: 20231232 [PubMed]
Preparations
First-Line Agents for acute rate control (rapid ventricular rate)
Precautions
Avoid these agents in
WPW Syndrome
or other accessory pathway (pre-excitation states)
Exercise
caution with rate control agents in
Pulmonary Hypertension
(dilated right heart)
Risk of
Cardiac Arrest
Atrial Flutter
is more difficult to rate control than
Atrial Fibrillation
However
Atrial Flutter
responds better to cardioversion
Hypotension
on presentation
All rate control agents will decrease
Blood Pressure
Consider electrical cardioversion
Consider
Calcium Gluconate
2 g IV prior to
Diltiazem
infusion (without bolus)
Consider
Magnesium
2 g IV infusion
Consider titratable, short-acting medications (e.g.
Esmolol
)
Background
Acute agent choice is often based on the agent patient is already taking
Consider
Diltiazem
IV if on a
Calcium Channel Blocker
Consider
Metoprolol
IV if on a
Beta Blocker
Diltiazem
IV is used most commonly for acute rate control in U.S. emergency departments
Diltiazem
IV may be preferred from study data
More rapid acting, more effective and with less risk of
Hypotension
than
Metoprolol
Fromm (2015) J Emerg Med 49(2):175-82 +PMID:25913166 [PubMed]
Metoprolol
IV is preferred if ejection fraction <35%
Diltiazem
Bolus: In 10-20 mg (or 0.35 mg/kg) increments up to 50 mg IV cummulative total bolus
Next: 5-20 mg/hour IV infusion
Avoid in
WPW Syndrome
or other accessory pathway or if ejection fraction <35%
If
Hypotension
occurs, consider
Calcium Gluconate
2 g IV (does not counter
AV Block
)
Metoprolol
Bolus: 5 mg IV every 5 minutes up to 3 doses (15 mg)
Next: 25-50 mg orally
Avoid in
WPW Syndrome
or other accessory pathway
Disposition
Avoid
Diltiazem
with
Metoprolol
(risk of
AV Block
)
If already on a rate control agent (e.g.
Metoprolol
or
Diltiazem
) when presented with RVR
Increase the oral dose of that agent after IV rate control achieved
If at maximum dose, consider adding
Digoxin
0.125 mg or
Amiodarone
(consult cardiology)
If not on a rate control agent, consider
Metoprolol
first
Oral
Metoprolol
appears more effective for chronic rate control than oral
Diltiazem
Contrast with IV forms, in which
Diltiazem
appears more effective in acute rate control
Preparations
Second-Line Agents for acute rate control (rapid ventricular rate)
Esmolol
Bolus: 500 mcg/kg IV over 1 minute
Next: 50 mcg/kg/min IV infusion
Next: Titrate dose every 5 to 15 minutes (maximum dose 200 mcg/kg/min)
Requires very close (1:1) monitoring
Avoid in
WPW Syndrome
or other accessory pathway
Magnesium
Bolus: 2.5 g IV over 20 minutes
Next: 2.5 g IV over 2 hours
Slow or stop infusion for
Hypotension
or respiratory depression
Procainamide
Bolus: 20-30 mg/min IV until controlled rate
Next: 2-6 mg/min IV up to 17 mg/kg
Stop for
Hypotension
or
QRS Widening
>50%
Amiodarone
Bolus: 150 to 300 mg IV
Next: 1 mg/min IV infusion
Prepare for
Hypotension
Digoxin
Bolus: 0.5 mg IV
Next: 0.25 mg orally at 4 and 8 hours
Avoid in
WPW Syndrome
or other accessory pathway
Protocol
Rate Control if
WPW Syndrome
with preserved heart function
Gene
ral
Risk of embolus if rhythm cardioverts
Consider
Atrial Fibrillation Anticoagulation
Avoid Harmful agents
Adenosine
Beta Blocker
Calcium Channel Blocker
Digoxin
Recommended agents (Use only 1 agent)
Electrical
Synchronized Cardioversion
if unstable
Class IA Agents
Procainamide
Class IC Agents
Propafenone
(
Rythmol
)
Flecainide
(
Tambocor
)
Class III Agents
Sotalol
(
Betapace
)
Mixed Evidence
Amiodarone
(
Cordarone
) may induce ventricular
Arrhythmia
s in WPW (per 2010
ACLS
guidelines)
Protocol
Rate control if WPW with Ejection Fraction <40%
Gene
ral
Risk of embolus if rhythm cardioverts
Consider
Atrial Fibrillation Anticoagulation
Recommended agents
Electrical
Synchronized Cardioversion
Amiodarone
(
Cordarone
)
Protocol
Rate control if Heart function preserved (No WPW)
Gene
ral
Risk of embolus if rhythm cardioverts
Consider
Atrial Fibrillation Anticoagulation
Recommended agents
Beta Blocker
s (preferred)
Metoprolol
(
Lopressor
) - preferred
Propranolol
(
Inderal
)
Esmolol
(
Brevibloc
)
Calcium Channel Blocker
Verapamil
(
Calan
)
Diltiazem
(
Cardizem
) - preferred
See
Diltiazem
for dosing protocol
Second line agents
Digoxin
Effect on
Heart Rate
is delayed 3 hours (contrast with 5 minutes for
Diltiazem
)
Amiodarone
Not as effective as
Diltiazem
or
Magnesium
for rate control in most cases
Used in critically ill patients with
Atrial Fibrillation
Clemo (1998) Am J Cardiol 81(5): 594-8 [PubMed]
Magnesium Sulfate
Effective adjunctive management of ventricular response rate control
Slows AV nodal conduction and decreases
Heart Rate
Davey (2005) Ann Emerg Med 45(4): 347-53 [PubMed]
Protocol
Rate control if Ejection Fraction <40% (No WPW)
Gene
ral
Risk of embolus if rhythm cardioverts
Consider
Atrial Fibrillation Anticoagulation
Recommended agents
Diltiazem
(
Cardizem
) - preferred
Amiodarone
Digoxin
(
Lanoxin
)
Avoid
Digoxin
for Atrial Fibrillation Rate Control outside of comorbid CHF
Increased mortaility when used for Atrial Fibrillation Rate Control
Whitbeck (2012) Eur Heart J 10.1093/eurheartj/ehs348
http://eurheartj.oxfordjournals.org/content/early/2012/11/14/eurheartj.ehs348.full
Management
Choosing Longterm Rate Versus Rhythm Control
Older studies compared rate control to medication-based rhythm control as treatment arm
Rate control has less drug-related adverse effects
Rate control has equivalent efficacy to rhythm control
Same survival benefit
Same
Cerebrovascular Accident
risk
Rhythm control may offer benefit in age <65 years
Wyse (2002) N Engl J Med 347:1825-33 [PubMed]
Newer studies compared rate control to catheter ablation
Catheter ablation appears superior to rate control in comorbid
Heart Failure
Marrouche (2018) N Engl J Med 378:417-27 [PubMed]
Rhythm control may be preferred in high risk cardiovascular patients in
Atrial Fibrillation
<1 year
NNT 91 to prevent one cardiovascular death, hospitalization or
Cerebrovascular Accident
in 5 years
But rhythm control is associated with serious complications in 2% of patients
Camm (2022) J Am Coll Cardiol 79(19): 1932-48 [PubMed]
Kirchhof (2020) N Engl J Med 383(14): 1305-16 [PubMed]
Management
Chronic Rate Control Agent Selection
Beta Blocker
s (e.g.
Metoprolol
) are typically most effective ORAL agents for rate control
Contrast with
Diltiazem
IV, which is typically more effective than IV
Beta Blocker
s
Avoid non-selective
Beta Blocker
s in acute CHF,
COPD
,
Asthma
Diltiazem
Associated with increased serious bleeding risk (compared with metroprolol) in those on
DOAC
s (e.g.
Apixaban
)
Ray (2024) JAMA 331(18): 1565-75 [PubMed]
References
(2000) Circulation, 102(Suppl I):86-9
http://www.circulationaha.org
Casaletto (2014) Crit Dec Emerg Med 28(4): 10-19
Orman, Mattu and Herbert in Herbert (2016) EM:Rap 16(9):6-7
Stiell (2011) Canadian J Cardiol 27(1): 38-46 [PubMed]
Wann (2011) Circulation 123(1): 104-23 [PubMed]
King (2002) Am Fam Physician 66(2):249-56 [PubMed]
Gutierrez (2011) Am Fam Physician 83(1): 61-8 [PubMed]
Falk (2001) N Engl J Med 344:1067-78 [PubMed]
Li (1998) Emerg Med Clin North Am 16:389-403 [PubMed]
Dell'Orfano (1998) Am Fam Physician, 58(2):471-80 [PubMed]
Hebbar (2002) Am Fam Physician 65(12):2479-86 [PubMed]
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