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Atrial Fibrillation

Bradycardia

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Atrial Fibrillation Rate Control

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  1. See Also
    1. Guidelines 2000 CPR and Emergency Cardiovascular Care
    2. Atrial Fibrillation
    3. Atrial Fibrillation Acute Management
    4. Atrial Fibrillation Anticoagulation
    5. Atrial Fibrillation Cardioversion
  2. Indications
    1. Atrial Fibrillation with rapid ventricular rate
  3. Precautions
    1. Beware agents which may cardiovert Atrial Fib >48 hours
      1. Risk of embolic complications
  4. Target Heart Rate
    1. Heart Rate: 70-90 bpm
  5. Rate Control: WPW Syndrome with preserved heart function
    1. General
      1. Risk of embolus if rhythm cardioverts
      2. Consider Atrial Fibrillation Anticoagulation
    2. Avoid Harmful agents
      1. Adenosine
      2. Beta Blocker
      3. Calcium Channel Blocker
      4. Digoxin
    3. Recommended agents (Use only 1 agent)
      1. Electrical Synchronized Cardioversion if unstable
      2. Class IA Agents
        1. Procainamide
      3. Class IC Agents
        1. Propafenone (Rythmol)
        2. Flecainide (Tambocor)
      4. Class III Agents
        1. Amiodarone (Cordarone)
        2. Sotalol (Betapace)
  6. Rate control: WPW with Ejection Fraction <40%
    1. General
      1. Risk of embolus if rhythm cardioverts
      2. Consider Atrial Fibrillation Anticoagulation
    2. Recommended agents
      1. Electrical Synchronized Cardioversion
      2. Amiodarone (Cordarone)
  7. Rate control: Heart function preserved (No WPW)
    1. General
      1. Risk of embolus if rhythm cardioverts
      2. Consider Atrial Fibrillation Anticoagulation
    2. Recommended agents
      1. Beta Blockers
        1. Propranolol (Inderal)
        2. Esmolol (Brevibloc)
        3. Metoprolol (Lopressor)
      2. Calcium Channel Blocker
        1. Verapamil (Calan)
        2. Diltiazem (Cardizem) - preferred
          1. See Diltiazem for dosing protocol
  8. Rate control: Ejection Fraction <40% (No WPW)
    1. General
      1. Risk of embolus if rhythm cardioverts
      2. Consider Atrial Fibrillation Anticoagulation
    2. Recommended agents
      1. Digoxin (Lanoxin)
      2. Diltiazem (Cardizem) - preferred
      3. Amiodarone
  9. Choosing longterm rate versus rhythm control
    1. Rate control has less drug-related adverse effects
    2. Rate control has equivalent efficacy to rhythm control
      1. Same survival benefit
      2. Same Cerebrovascular Accident risk
    3. Rhythm control may offer benefit in age <65 years
    4. References
      1. Wyse (2002) N Engl J Med 347:1825
  10. References
    1. Dell'Orfano (1998) Am Fam Physician 58(2):471
    2. Hebbar (2002) Am Fam Physician 65(12):2479
    3. King (2002) Am Fam Physician 66:249
    4. (2000) Circulation, 102(Suppl I):86-9
    5. http://www.circulationaha.org

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