Acute rate control in atrial fibrillation: an urgent need for the clinician

Abstract

Rate and rhythm control are still considered equivalent strategies for symptom control using the Atrial Fibrillation Better Care algorithm recommended by the recent atrial fibrillation guideline. In acute situations or critically ill patients, a personalized approach should be used for rapid rhythm or rate control. Even though electrical cardioversion is generally indicated in haemodynamically unstable patients or for rapid effective rhythm control in critically ill patients, this is not always possible due to the high percentage of failure or relapses in such patients. Rate control remains the background therapy for all these patients, and often rapid rate control is mandatory. Short and rapid-onset-acting beta-blockers are the most suitable drugs for acute rate control. Esmolol was the classical example; however, landiolol a newer very selective beta-blocker, recently included in the European atrial fibrillation guideline, has a more favourable pharmacokinetic and pharmacodynamic profile with less haemodynamic interference and is better appropriate for critically ill patients.

Dexmedetomidine as an effective alternative tool for heart rate control in atrial fibrillation during general anesthesia—A case report

“…Additionally, diltiazem has been reported to have limited efficacy in HR control. [ 5 6 ] Amiodarone should be administered with careful consideration of its side effects and risk/benefit profile. [ 7 ] While these medications are considered standard for AF HR control, it may be worthwhile to consider dexmedetomidine in certain situations.…”

Intravenous Landiolol for Rate Control in Supraventricular Tachyarrhythmias in Patients with Left Ventricular Dysfunction: A Systematic Review and Meta-Analysis

“…For patients with HF who experience tachyarrhythmia, the options for acute pharmaceutical interventions are limited [ 34 ]. For hemodynamically stable patients, opting for rate control is a viable strategy until further planning is established, as in cases of AF, when ensuring the coagulation status precedes cardioversion [ 35 , 36 , 37 ]. In patients with LVEF < 40%, apart from beta-blockers, only digoxin is an alternative option for rapid rate control [ 38 ].…”

The Optimal Management of Patients with Atrial Fibrillation and Acute Heart Failure in the Emergency Department

“…On the other hand, pharmacological cardioversion does not require sedation and analgesia. The selection of the mode of elective cardioversion is influenced by local practices and hospital protocols and is subject to geographic variations [1,2,59]. The RHYTHM-AF trial revealed that Sweden, Australia, United Kingdom and Germany adopted ECV as the main strategy, whereas Italy, Spain and Brazil had a strong preference for pharmacological cardioversion [60].…”

“…This is due to the fact that amiodarone has a favorable safety profile and carries a low risk of proarrhythmia. The only disadvantage is its delayed onset of action (8-24 h) [1,2,59].…”