AF control

The initial management of patients with AF and a rapid ventricular rate involves two decisions:

• Determining the urgency of initial therapy (eg, intravenous versus oral rate control therapy, and/or immediate versus elective cardioversion).
• Choosing between a rate control and a rhythm control strategy.

Rate vs rhythm - AFFIRM and RACE trial has shown that rate and rhythm control have similar outcomes.

Rate control

Beta-blockers, usually metoprolol. IV for acute control, oral for chronic control

Complications: worsening heart failure, bronchospasms(COPD), hypotension, reduced exercise tolerance.

CCB, usually verapamil. Verapamil increases refractoriness and decreases conduction velocity in the AV node. These drugs can be used intravenously for acute rate control and can produce long-term rate slowing when used orally.

Digoxin, lows the ventricular rate during AF primarily by vagotonic inhibition of AV nodal conduction. It is generally less effective for rate control than beta blockers or calcium channel blockers, particularly during exercise when vagal tone is low and sympathetic tone is high (see 'Comparative efficacy' below [10,17,18,34-39]. Furthermore, digoxin has no ability to terminate AF. In HF, increases contractility and reduction in ventricular rate.

Plasma digoxin levels should be monitored periodically. Although the correlation between drug concentration and ventricular rate control is poor, the presence of a low serum digoxin concentration is useful in that it allows a higher dose to be administered.

Junctional escape beats (detected by the equality of all of the longest observed R-R intervals on the electrocardiogram) are common when digitalis has successfully slowed the ventricular rate. Giving more digoxin in this setting will increase the degree of AV nodal block and produce periods of a regular junctional escape rhythm. The change from single junctional escapes to periodic junctional rhythm usually signifies the development of digoxin toxicity.

Rhythm control

Reversion to NSR - pharmacological or direct cardioversion

DC cardioversion is indicated in patients who are hemodynamically unstable, a setting in which the AF is typically of short duration. In stable patients in whom spontaneous reversion due to correction of an underlying disease is not likely, either DC or pharmacologic cardioversion can be performed (table 2 and table 3A-B). Electrical cardioversion is usually preferred because of greater efficacy and a low risk of proarrhythmia. The overall success rate (at any level of energy) of electrical cardioversion for AF is 75 to 93 percent and is related inversely both to the duration of AF and to left atrial size [13]. (See "Restoration of sinus rhythm in atrial fibrillation: Therapeutic options".)A number of antiarrhythmic drugs are more effective than placebo, converting 30 to 60 percent of patients [14]. Evidence of efficacy from randomized trials is best established for ibutilide, flecainide, dofetilide, propafenone, and amiodarone

No structural heart disesae - fleclanide
Structural heart disease - amiodarone or sotalol