Medical management of AF: drugs for rate and rhythm control
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2 Medical management of AF: drugs for rate and rhythm control Adel Khalifa Sultan Hamad, BMS, MD, FGHRS, FRCP(Canada) Consultant Cardiologist & Interventional Cardiac Electrophysiologist Head of Electrophysiology Department Mohammed bin Khalifa Al Khalifa Cardiac Centre Bahrain Defence Force Hospital October 19, 2017
3 Disclosures: Nil
4
5 Management of AF Rate control Rhythm control Acute rate control Long-term rate control Acute restoration of SR Long-term rhythm control Medical therapy / AVN ablation Medical therapy / Electrical cardioversion Medical therapy Medical therapy / Ablation
6 Rate control therapy in atrial fibrillation Therapy Acute IV rate control Long-term oral rate control Beta-blockers Bisoprolol N/A mg OD Carvedilol N/A mg bid Metoprolol mg IV bolus mg total dose Nebivolol N/A mg OD Esmolol 0.5 mg/kg IV bolus over 1 min then mg/kg/min 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS, European Heart Journal (2016) 37, N/A
7 Rate control therapy in atrial fibrillation Therapy Acute IV rate control Long-term oral rate control Calcium-channel blockers Diltiazem Verapamil mg IV bolus mg IV bolus 60 mg tid daily up to 360 mg total daily dose ( mg once daily modified release) mg tid daily ( mg once daily modified release) 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS, European Heart Journal (2016) 37,
8 Rate control therapy in atrial fibrillation Therapy Acute IV rate control Long-term oral rate control Cardiac glycosides Digoxin 0.5 mg IV bolus ( mg over 24 hrs in divided doses) mg daily dose Digitoxin mg IV bolus mg daily dose 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS, European Heart Journal (2016) 37,
9 Rate control therapy in atrial fibrillation Therapy Acute IV rate control Long-term oral rate control Specific indications Amiodarone 300 mg IV diluted in 250 mg 5% dextrose over minutes (preferably via central venous cannula) 200 mg daily 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS, European Heart Journal (2016) 37,
10 Rate control therapy in atrial fibrillation 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. Circulation. 2014;130:e199-e267
11 Rate control therapy in atrial fibrillation 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS, European Heart Journal (2016) 37,
12 Heart Rate Targets in Atrial Fibrillation The RACE (Rate Control Efficacy in Permanent Atrial Fibrillation) II study Van Gelder IC et al. N Engl J Med 2010;362:
13 Atrioventricular node ablation and pacing Simple procedure Low complication rate Low long-term mortality risk The choice between RV pacing, BiV pacing ± ICD Best candidates: elderly, refractory symptoms & heart rate despite medical therapy
14 Rhythm control therapy in atrial fibrillation Antiarrhythmic drugs for pharmacological cardioversion Drug Route 1 st dose F/U dose Flecainide Oral IV mg mg/kg over 10 min Amiodarone IV 5 7 mg/kg over 1 2 hrs Propafenone Oral IV mg mg/kg over 10 min 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS, European Heart Journal (2016) 37, N/A 50 mg/hr to a max of 1.0 g over 24 hrs Ibutilide IV 1 mg over 10 min 1 mg over 10 min Vernakalant IV 3 mg/kg over 10 min 2 mg/kg over 10 min N/A
15 Rhythm control therapy in atrial fibrillation Antiarrhythmic drugs for pharmacological cardioversion 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS, European Heart Journal (2016) 37,
16 Rhythm control therapy in atrial fibrillation Oral antiarrhythmic drugs used for maintaining sinus rhythm after cardioversion Drug Dose Warning signs warranting discontinuation AV nodal slowing Amiodarone 600 mg in divided doses for 4 wks, 400 mg for 4 wks, then 200 mg od QT prolongation >500 ms bpm in AF Dronedarone 400 mg bid QT prolongation >500 ms bpm in AF Flecainide mg bid QRS duration increases >25% above baseline None Propafenone mg tid QRS duration increases >25% above baseline Slight d,l Sotalol mg bid QT prolongation >500 ms. QT prolongation by 60ms upon therapy initiation Similar to high dose BB 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS, European Heart Journal (2016) 37,
17 Rhythm control therapy in atrial fibrillation Oral antiarrhythmic drugs used for maintaining sinus rhythm after cardioversion 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS, European Heart Journal (2016) 37,
18 Rhythm control therapy in atrial fibrillation Oral antiarrhythmic drugs used for maintaining sinus rhythm after cardioversion 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. JACC. 2014:64 (21)
19 Rhythm control therapy in atrial fibrillation New antiarrhythmic drugs Inhibitors of ultrarapid K current (I Kur ) Ranolazine Ivabradine
20 Rhythm control therapy in atrial fibrillation Antiarrhythmic effects of non-antiarrhythmic drugs ACE Inhibitors ARB Neprilysin Inhibitors Statin Aldosterone Antagonists PUFA
21 Thank you
22 Summary of recommendations for rate control Recommendations COR LOE Control of ventricular rate using BB or nondihydropyridine CCB for paroxysmal, persistent or permanent AF I B IV BB or nondihydropyridine CCB is recommended to slow the VHR in the acute setting in patients without pre-excitation. In hemodynamically unstable patients electrical cardioversion is indicated For AF, assess heart rate control during exertion, adjusting pharmacological treatment as necessary I C AV nodal ablation should not be performed without prior attempts to achieve rate control with medications III C Nondihydropyridine calcium channel antagonists should not be used in decompensated HF III C With pre-excitation and AF, digoxin, nondihydropyridine calcium channel antagonists, or amiodarone should not be administered Dronedarone should not be used to control ventricular rate with permanent AF III B I III B B 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS, European Heart Journal (2016) 37,
23 References ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. European Heart Journal (2016) 37, AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive Summary. JACC VOL. 64, NO. 21, 2014
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