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Drug management of atrial fibrillation

Authoring team

There are three main therapeutic aims in the drug treatment of atrial fibrillation:

  • control of the ventricular rate (1):
    • in patients with permanent AF, who need treatment for rate-control:
      • beta-blockers or rate-limiting calcium antagonists should be the preferred initial monotherapy in all patients
      • digoxin should only be considered as monotherapy in predominantly sedentary patients
  • chemical cardioversion to sinus rhythm:
    • class IV, I and III drugs
  • prevention of thromboembolism:
    • anticoagulation with warfarin or aspirin

Note: there is evidence from two large randomised trials (2,3) that have shown that a rate-control strategy is at least as effective as rhythm control

  • there was a strong trend for patients in the rate-control group to have fewer major clinical events (and patients in this treatment group had fewer adverse events)
  • t is unclear when a rhythm-control strategy might be preferred. Possible instances might be (4):
    • a recent-onset AF with a low risk of recurrence - in a case where there is an obvious precipitant and no underlying structural heart disease, for example, a patient with a pyrexial illness such as pneumonia or AF occurring after an alcoholic binge or following an operation
    • intolerable symptoms despite adequate rate control
    • patients at high risk from warfarin or aspirin therapy

  • NICE have stated that (1):
    • When to offer rate or rhythm control Rate control
      • offer rate control as the first-line strategy to people with atrial fibrillation, except in people:
        • whose atrial fibrillation has a reversible cause
        • who have heart failure thought to be primarily caused by atrial fibrillation
        • with new-onset atrial fibrillation
        • with atrial flutter whose condition is considered suitable for an ablation strategy
        • to restore sinus rhythm for whom a rhythm control strategy
        • would be more suitable based on clinical judgement
      • offer either a standard beta-blocker (that is, a beta-blocker other than sotalol) or a rate-limiting calcium-channel blocker as initial monotherapy to people with atrial fibrillation who need drug treatment as part of a rate control strategy. Base the choice of drug on the person's symptoms, heart rate, comorbidities and preferences when considering drug treatment

      • digoxin should only be considered as monotherapy if
        • the person does no or very little physical exercise or
        • other rate-limiting drug options are ruled out because of comorbidities or the person's preferences

      • if monotherapy does not control symptoms, and if continuing symptoms are thought to be due to poor ventricular rate control, consider combination therapy with any 2 of the following:
        • a beta-blocker
        • diltiazem
        • digoxin

      • do not offer amiodarone for long-term rate control

Notes:

  • previous NICE guidance had stated (5):

    • in patients with permanent AF, where monotherapy is inadequate:
      • to control the heart rate only during normal activities, beta-blockers or rate-limiting calcium antagonists should be given with digoxin
      • to control the heart rate during both normal activities and exercise, rate-limiting calcium antagonists should be given with digoxin
    • patients unsuitable for cardioversion include those with:
      • contraindications to anticoagulation
      • structural heart disease (e.g. large left atrium >5.5 cm, mitral stenosis) that precludes long-term maintenance of sinus rhythm
      • a long duration of AF (usually >12 months)
      • a history of multiple failed attempts at cardioversion and/or relapses, even with concomitant use of antiarrhythmic drugs or non-pharmacological approaches
      • an ongoing but reversible cause of atrial fibrillation (e.g. thyrotoxicosis)

Reference:

  1. NICE (April 2021). Atrial Fibrillation.
  2. Wyse DG, Waldo AL, DiMarco JP, et al. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med 2002;347:1825-33.
  3. Van Gelder IC, Hagens VE, Bosker HA, et al. A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation. N Engl J Med 2002;347:1834-40.
  4. Prescriber 2003; 14(14): 25-33.
  5. NICE (June 2006). Atrial Fibrillation.

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