Rate Control for Atrial Fibrillation: What Is the Best Drug to Use?
In a small, randomized crossover trial of four commonly prescribed beta- and calcium-channel blockers, diltiazem emerged the winner.
Current guidelines recommend either a beta-blocker or a calcium-channel blocker as first-line rate-control treatment for atrial fibrillation (AF). However, head-to-head trials of the agents in current use are lacking. To compare the effects of four once-daily drug regimens on heart rate and AF-related symptoms in patients with permanent, rapidly conducted AF, investigators in Norway conducted a prospective, randomized, investigator-blind, crossover study. Sixty adults (mean age, 71; 18 women) with permanent AF and without congestive heart failure or ischemic heart disease received, in randomized order, diltiazem, 360 mg; verapamil, 240 mg; metoprolol, 100 mg; and carvedilol, 25 mg. Each drug was given for 3 weeks to ensure steady-state plasma concentration and adequate washout of the prior treatment. Before the first treatment and on the last day of each treatment protocol, 24-hour Holter recordings were obtained, and patients completed questionnaires on symptom frequency and severity.
The 24-hour mean heart rate was significantly reduced from baseline with all four treatments and was significantly lower with diltiazem than with any other drug:
Compared with baseline, diltiazem treatment significantly reduced both the frequency and severity of symptoms. Verapamil significantly reduced symptom frequency only, and metoprolol and carvedilol improved neither frequency nor severity. Reported symptoms were more frequent and more severe in women than in men, both at baseline and during all drug treatments.
CITATION(S):
Ulimoen SR et al. Comparison of four single-drug regimens on ventricular rate and arrhythmia-related symptoms in patients with permanent atrial fibrillation. Am J Cardiol 2013 Jan 15; 111:225.
