Atrial Fibrillation Rate Control

For stable permanent AF with heart failure, use a resting ventricular rate below 110 beats/min as a practical initial target. In the heart-failure subgroup of RACE II, lenient control defined by resting heart rate below 110 beats/min was as effective as strict control defined by resting heart rate below 80 beats/min plus a rate below 110 beats/min during moderate exercise; target attainment was higher with lenient control (94.6% versus 73.8%). AHA JournalsAHA JournalsAbstract 16829: Stringency of Rate Control in Patients with Atrial Fibrillation and Heart Failure: Data of the Rate Control Efficacy in Permanent Atrial Fibrillation: a Comparison between Lenient versus Strict Rate Control II (RACE II) Study

Do not intensify rate-slowing therapy solely to reach a resting rate below 80 beats/min when the patient is clinically stable at a rate below 110 beats/min. Lenient control was not independently associated with adverse left-atrial or left-ventricular remodeling in permanent AF, and strict targets required more treatment visits. jacc+1jaccEffect of Lenient Versus Strict Rate Control on Cardiac Remodeling in Patients With Atrial Fibrillation: Data of the RACE II (RAte Control Efficacy in permanent atrial fibrillation II) Study | JACCAHA JournalsAbstract 16829: Stringency of Rate Control in Patients with Atrial Fibrillation and Heart Failure: Data of the Rate Control Efficacy in Permanent Atrial Fibrillation: a Comparison between Lenient versus Strict Rate Control II (RACE II) Study

Escalate beyond a rate-control-only strategy when AF appears to be driving heart-failure morbidity despite pharmacologic rate control. AF and heart failure amplify one another clinically, and catheter ablation has been tested specifically in patients with AF and heart failure; evaluate candidacy for AF ablation before committing a refractory patient to AV-node ablation and permanent pacing. NEJM+2NEJMCatheter Ablation for Atrial Fibrillation with Heart FailureNEJMRhythm Control versus Rate Control for Atrial Fibrillation and Heart ...ScienceDirectBeta-Blockers and Outcome in Heart Failure and Atrial Fibrillation: A Meta-Analysis

In AF with LV systolic dysfunction, use a beta-blocker as the preferred pharmacologic foundation for ventricular rate control when tolerated. Beta-blockers reduce ventricular rate in AF and have established prognostic benefit in heart failure with LV systolic dysfunction; in AF plus heart failure, available trials suggest beta-blockers reduce ventricular rate, improve ventricular function, and are tolerated. jacc+1jaccCarvedilol alone or in combination with digoxin for the management of atrial fibrillation in patients with heart failure?jaccVentricular rate control in chronic atrial fibrillation during daily activity and programmed exercise: a crossover open-label study of five drug regimens

Avoid treating digoxin monotherapy as adequate control in an ambulatory, physically active patient. Digoxin reduced resting heart rate in chronic AF but did not reduce heart rate during exercise. When inadequate resting or exertional control persists on tolerated beta-blockade, digoxin can be added for AV-nodal synergy; combined atenolol plus digoxin produced lower 24-hour and exercise ventricular rates than digoxin, diltiazem, or digoxin plus diltiazem in a crossover study. dailymed nlm nih+1dailymed nlm nihThese highlights do not include all the information needed to use DIGOXIN TABLETS safely and effectively. See full prescribing information for DIGOXIN TABLETS. DIGOXIN tablets, for oral use Initial U.S. Approval: 1954jaccVentricular rate control in chronic atrial fibrillation during daily activity and programmed exercise: a crossover open-label study of five drug regimens

Avoid non-dihydropyridine calcium-channel blockers as the routine alternative in heart failure. Reviews identify beta-blockers and digoxin as rate-control options in heart failure, while non-dihydropyridine calcium-channel blockers are described as effective rate-control agents outside heart failure; concerns specifically exist regarding diltiazem safety in heart failure. jacc+1jaccCarvedilol alone or in combination with digoxin for the management of atrial fibrillation in patients with heart failure?ScienceDirectBeta-Blockers and Outcome in Heart Failure and Atrial Fibrillation: A Meta-Analysis

Reserve chronic amiodarone-based rate control for situations in which preferred AV-nodal strategies are not usable or have failed and a rhythm-control effect is acceptable. Amiodarone reduced ventricular rate and was associated with more spontaneous cardioversion than placebo in a heart-failure subgroup analysis, but long-term toxicities and the prognostic advantage of beta-blockers favor beta-blockers for persistent AF with LV systolic dysfunction. jaccjaccCarvedilol alone or in combination with digoxin for the management of atrial fibrillation in patients with heart failure?

Avoid digoxin when the heart-failure phenotype includes restrictive cardiomyopathy, constrictive pericarditis, amyloid heart disease, acute cor pulmonale, or idiopathic hypertrophic subaortic stenosis unless ventricular rate control in AF is judged necessary and alternatives are unsuitable. Digoxin can reduce cardiac output in several preserved-ejection-fraction conditions, can worsen outflow obstruction in hypertrophic subaortic stenosis, and amyloid heart disease increases susceptibility to toxicity even at therapeutic concentrations. dailymed nlm nihdailymed nlm nihThese highlights do not include all the information needed to use DIGOXIN TABLETS safely and effectively. See full prescribing information for DIGOXIN TABLETS. DIGOXIN tablets, for oral use Initial U.S. Approval: 1954

When combining digoxin with a beta-blocker, monitor for excessive AV-nodal suppression and bradycardia. Both drug classes slow AV conduction and heart rate; concomitant administration increases bradycardia risk. Sotalol labeling also reports more proarrhythmic events among sotalol-treated patients receiving digoxin, although whether this is causal or reflects concomitant heart failure is uncertain. dailymed nlm nihdailymed nlm nihSotalol Hydrochloride Tablets, USP (AF) 80 mg, 120 mg, and 160 mg

Counseling and follow-up should focus on toxicity-related rhythm disturbance rather than assuming a therapeutic response from resting pulse alone. Digoxin toxicity commonly manifests with dysrhythmias, and its limited exercise rate control means persistent exertional palpitations or dyspnea should prompt reassessment of the rate-control regimen rather than automatic dose escalation. dailymed nlm nih+1dailymed nlm nihThese highlights do not include all the information needed to use DIGOXIN TABLETS safely and effectively. See full prescribing information for DIGOXIN TABLETS. DIGOXIN tablets, for oral use Initial U.S. Approval: 1954Wolters KluwerEvidenced-Based Pharmacotherapy for Rate Control in Atrial...

Consider catheter ablation of AF in heart-failure patients whose symptoms, recurrent decompensation, or ventricular dysfunction remain attributable to AF despite a reasonable rate-control attempt. Catheter ablation has been evaluated in patients with AF and heart failure, and expert synthesis recommends considering AF ablation before AV-node ablation for rate control. NEJM+1NEJMCatheter Ablation for Atrial Fibrillation with Heart FailureScienceDirectBeta-Blockers and Outcome in Heart Failure and Atrial Fibrillation: A Meta-Analysis

Use AV-node ablation with pacemaker implantation as a definitive rate-control option when drug therapy has not produced acceptable control and AF ablation is not appropriate, has failed, or is declined. This approach is considered a last resort for rate control, but may be considered earlier in patients already managed with cardiac resynchronization therapy. ScienceDirectScienceDirectBeta-Blockers and Outcome in Heart Failure and Atrial Fibrillation: A Meta-Analysis

After AV-node ablation, the procedural tradeoff is permanent pacemaker dependence; therefore, define the goal before referral as durable ventricular-rate regularization rather than restoration of sinus rhythm. Patients receiving cardiac resynchronization therapy represent a distinct group in whom earlier AV-node ablation may be considered to support the pacing strategy. ScienceDirectScienceDirectBeta-Blockers and Outcome in Heart Failure and Atrial Fibrillation: A Meta-Analysis

Do not use sotalol as a simple rate-control substitute in a patient with substantial renal dysfunction, dialysis dependence, or obstructive lung disease; its labeling lists serious kidney problems or dialysis and pulmonary disease causing shortness of breath, including asthma, chronic bronchitis, and emphysema, among contraindication-related patient warnings. Sotalol also produces dose-related QTc prolongation and carries a proarrhythmic risk. dailymed nlm nihdailymed nlm nihSotalol Hydrochloride Tablets, USP (AF) 80 mg, 120 mg, and 160 mg

If dofetilide is being considered as part of a rhythm-control strategy rather than for routine rate control, treat QT prolongation and torsade de pointes risk as the central safety constraints. Dofetilide produces a dose-related QT increase, and clinical evaluation specifically assessed torsade de pointes frequency according to dose. dailymed nlm nihdailymed nlm nihTIKOSYN ® (dofetilide) Capsules

Do not add multiple AV-nodal agents without reassessing bradycardia, hypotension, and the clinical target. Sotalol plus digoxin can increase bradycardia risk, and sotalol combined with calcium-channel blockers can produce additive effects on AV conduction, ventricular function, and blood pressure. dailymed nlm nihdailymed nlm nihSotalol Hydrochloride Tablets, USP (AF) 80 mg, 120 mg, and 160 mg