Abstract
Atrial fibrillation is the most common arrhythmia in the general population and is frequently associated with organic heart disease. β-adrenoceptor antagonists (β-blockers) are very effective in preventing atrial fibrillation after coronary artery bypass surgery It has been shown recently that the β-blocker metoprolol controlled release/extended release (CR/XL) is also effective in maintaining sinus rhythm after conversion of atrial fibrillation. There is concern that class I antiarrhythmic drugs, such as quinidine, disopyramide, and flecainide in particular, may increase mortality. The risk of proarrhythmia associated with β-blocker treatment is very low. Therefore β—blockers, such as metoprolol CR/XL, may be the first line of treatment to maintain sinus rhythm, especially after myocardial infarction and in patients with chronic heart failure and in those with arterial hypertension.
In patients with persistent atrial fibrillation, AV-nodal conduction-slowing drugs, such as calcium channel antagnoists and β-blockers are used to control the ventricular rate during atrial fibrillation. Several studies clearly show that β-blockers alone, or in combination with digoxin are very effective in controlling the ventricular rate at rest and during exercise, β-blockers are effective in maintaining sinus rhythm and controlling the ventricular rate during atrial fibrillation. Given these effects and their favorable effects on mortality, β-blockers should be considered as first-line agents in the management of patients with atrial fibrillation.
Similar content being viewed by others
References
Kannel WB, Abbott RD, Savage DD, et al. Epidemiologic features of chronic atrial fibrillation: the Framingham study. N Engl J Med 1982; 306: 1018–22
Feinberg WM, Blackshear JL, Laupacis A, et al. Prevalence, age distribution, and gender of patients with atrial fibrillation. Arch Intern Med 1995; 155: 469–73
Benjamin EJ, Levy D, Vaziri EM, et al. Independent risk factors for atrial fibrillation in a population-based cohort: the Framingham Heart Study. JAMA 1994; 271: 840–4
Atrial Fibrillation Investigators: risk factors for stroke and efficacy of antithrombotic therapy in atrial fibrillation: analysis of pooled data from five randomized controlled trials. Arch Intern Med 1994; 154: 1449–57
Carlsson J, Neuzner J, Rosenberg YD. Therapy of atrial fibrillation: rhythm control versus rate control. Pacing Clin Electrophysiol 2000; 23: 891–903
Hohnloser SH, Kuck KH, Lilienthal J. Rhythm or rate control in atrial fibrillation. Pharmacological intervention in atrial fibrillation (PIAF): a randomised trial. Lancet 2000; 356: 1789–94
Psaty BM, Manolio TA, Kuller LH, et al. Incidence of and risk factors for atrial fibrillation in older adults. Circulation 1997; 96: 2455–61
Kowey PR, Taylor JE, Rials SJ, et al. Meta-analysis of the effectiveness of prophylactic drug therapy in preventing supraventricular arrhythmia early after coronary artery bypass grafting. Am J Cardiol 1992; 69: 863–5
Fuchs T, Podrid PJ. Pharmacologic therapy for reversion of atrial fibrillation and maintenance of sinus rhythm. In: Falk RH, Podrid PJ, editors. Atrial fibrillation. Mechanisms and management. New York: Raven Press, 1992: 233–51
Juul-Möller S, Edvardsson N, Rehnquist-Ahlberg N. Sotalol versus quinidine for the maintenance of sinus rhythm after direct current conversion of atrial fibrillation. Circulation 1990; 82: 1932–9
Nattel S, Feder-Elituv R, Matthews C, et al. Concentration dependence of class III and beta-adrenergic blocking effects of sotalol in anesthetized dogs. J Am Coll Cardiol 1989; 13: 1190–4
Edvardsson N, Huikkuri H, Kennebäck G, et al. Antiarrhythmic efficacy by a class III agent with and without betablockade in chronic atrial fibrillation — a double blind randomized comparison of d,l sotalol, d sotalol and placebo [abstract]. J Am Coll Cardiol 1996; 27 Suppl.; 46A
Funck-Brentano C, Kibleur Y, Le Coz F, et al. Rate dependence of sotalol induced prolongation of ventricular repolarization during exercise in humans. Circulation 1991; 83: 536–45
Plewan A, Lehman G, Ndrepepa G, et al. Maintenance of sinus rhythm after electrical cardioversion of persistent atrail fibrillation: sotalol vs bisoprolol. Eur Heart J 2001: 22(16): 1504–10
Steeds RP, Birchall AS, Smith M, et al. An open label, randomised, crossover study comparing sotalol and atenolol in the treatment of symptomatic paroxysmal atrial fibrillation. Heart 1999; 82: 170–5
Fischer F, Schwacke H, Rameken M, et al. Frequency of symptomatic recurrences of atrial fibrillation after successful electrical cardioversion of atrial fibrillation in patients treated with metoprolol in comparison to sotalol. J Am Coll Cardiol 2001; 37 Suppl.: 648A
Kühlkamp V, Schirdewan A, Stangl K, et al. Use of Metoprolol CR/XL to maintain sinus rhythm after conversion from persistent atrial fibrillation. A randomized double blind placebo controlled study. J Am Coll Cardiol 2000; 36: 139–46
Chen SA, Hsieh MH, Tai CT, et al. Initiation of atrial fibrillation by ectopic beats originating from the pulmonary veins: electrophysiological characteristics, pharmacological responses, and effects of radiofrequency ablation. Circulation 1999; 100: 1879–86
Campbell DL, Rasmusson RL, Comer MB, et al. The cardiac calcium-independent outward potassium current: kinetics, molecular properties, and role in ventricular repolarization. In: Zipes DP, Jalife J, editors. Cardiac electrophysiology. from cell to bedside. Philadelphia: W.B.Saunders Company, 1995: 83–96
Daoud EG, Bogun F, Harvey M, et al. Effect of atrial fibrillation on atrial refractoriness in humans. Circulation 1996; 94: 1600–6
Wang Z, Fermini B, Nattel S. Sustained depolarization-induced outward current in human atrial myocytes: evidence for a novel delayed rectifier K+ current similar to Kv1.5 cloned channel currents. Circ Res 1993; 73: 1061–76
Li G-R, Feng J, Wang Z, et al. Adrenergic modulation of ultrarapid delayed rectifier K current in human atrial myocytes. Circ Res 1996; 78: 903–15
Crijns HJGM, van Gelder IC, Lie KI. Benefits and risks of antiarrhythmic drug therapy after DC electrical cardioversion of atrial fibrillation or flutter. Eur Heart J 1994: 15 Suppl. A: 17–21
Page RL. Beta-blockers for atrial fibrillation: must we consider asymptomatic arrhythmias? J Am Coll Cardiol 2000; 36: 147–50
Fetsch T, Burschel G, Breithardt G, et al. Die medikamentose Prophylaxe nach elektronischer Kardioversion von chronischem Vorhofflimmern. Ziele und Design der PAFAC-Studie. Z Kardiol 1999; 88: 195–207
Fetsch T, Breithardt G, Engberding R, et al. Prevention of atrial fibrillation after cardioversion — results of PAFAC Trial [abstract]. Circulation 2001; 104 Suppl. II: 699
Fetsch T, Breithardt G, Engberding R, et al. Can we believe in symptoms for detention of atrial fibrillation in clinical routine? Results of the PAFAC trial. [abstract]. Circulation 2001; 104 Suppl. II: 699
Roy D, Talajic M, Dorian P, et al. Amiodarone to prevent recurrence of atrial fibrillation. N Engl J Med 2000; 342: 913–20
Singh SN, Fletcher RD, Gross Fisher S, et al. The Survival Trial of Antiarrhythmic Therapy in Congestive Heart Failure: amiodarone in patients with congestive heart failure and asymptomatic ventricular arrhythmia. N Engl J Med 1995; 333: 77–82
Cairns JA, Connolly SJ, Roberts R, et al. Randomised trial of outcome after myocardial infarction in patients with frequent or repetitive ventricular depolarisations: CAMIAT. Lancet 1997; 349: 675–82
Julian DG, Camm AJ, Frangin G, et al. Randomised trial of effect of amiodarone on mortality in patients with left-ventricular dysfunction after recent myocardial infarction: EMIAT. Lancet 1997; 349: 667–74
Antman EM, Beamer AD, Cantillon CO, et al. Therapy of refractory symptomatic atrial fibrillation and atrial flutter: A staged care approach with new antiarrhythmic drugs. J Am Coll Cardiol 1990; 15: 698–707
Graboys TB, Podrid PJ, Lown B. Efficacy of amiodarone for refractory supraventricular tachyarrhythmias. Am Heart J 1983; 106: 870–6
Chin SH, Sager PT, Stevenson WG, et al. Long term efficacy of amiodarone for the maintenance of normal sinus rhythm in patients with refractory atrial fibrillation or flutter. Am J Cardiol 1995; 76: 47–50
Platia EV, Michelson EL, Porterfield JK, et al. Esmolol versus verapamil in the acute treatment of atrial fibrillation or atrial flutter. Am J Cardiol 1989; 63: 925–9
Shettigar UR, Toole JG, Appunn DO. Combined use of esmolol and digoxin in the acute treatment of atrial fibrillation or flutter. Am Heart J 1993; 126: 368–74
Rawles JM. What is meant by a ‘controlled’ ventricular rate in atrial fibrillation? Br Heart J 1990; 63: 157–61
Grogan M, Smith HC, Gersh BJ, et al. Left ventricular dysfunction due to atrial fibrillation in patients initially believed to have idiopathic dilated cardiomyopathy. Am J Cardiol 1992; 69: 1570–3
Falk RH. Control of the ventricular rate in atrial fibrillation. Falk RH, Podrid (eds) PJ. Atrial fibrillation. mechanisms and management 1992 New York: Raven Press, 1992: 255–82
Saksena S, Klein GJ, Kowey PR, et al. Electrophysiologic effects, clinical efficacy and safety of intravenous and oral nadolol in refractory supraventricular tachyarrhythmias. Am J Cardiol 1987; 59: 307–12
DiBianco R, Morganroth J, Freitag JA, et al. Effects of nadolol on the spontaneous and exercise-provoked heart rate of patients with chronic atrial fibrillation receiving stable dosages of digoxin. Am Heart J 1984; 108: 1121–7
Abrams J, Allen J, Allin D, et al. Efficacy and safety of esmolol vs propranolol in the treatment of supraventricular tachyarrhythmias: a multicenter double-blind clinical trial. Am Heart J 1985; 110: 913–22
Atwood JE, Sullivan MJ, Forbes SM, et al. Effect of beta-adrenergic blockade on exercise performance in patients with chronic atrial fibrillation. J Am Coll Cardiol 1987; 10: 314–20
Koh KK, Kwon KS, Park HB, et al. Efficacy and safety of digoxin alone and in combination with low-dose diltiazem or betaxolol to control ventricular rate in chronic atrial fibrillation. Am J Cardiol 1995; 75: 88–90
Farshi R, Kistner D, Sarma JS, et al. Ventricular rate control in chronic atrial fibrillation during daily activity and programmed exercise: a crossover open-label study of five drug regimens. J Am Coll Cardiol 1999; 33: 304–10
Lechat P, Hulot JS, Escolano S, et al. Heart rate and cardiac rhythm relationships with bisoprolol benefit in chronic heart failure in CIBIS II Trial. Circulation 2001; 103: 1428–33
The Planning and Steering Committees of the AFFIRM Study for the NHLBI AFFIRM Investigators: atrial fibrillation follow-up investigation of rhythm management: the AFFIRM study design. Am J Cardiol 1997; 79: 1198–202
Coumel P. Neural aspects of paroxysmal atrial fibrillation. In: Falk RH, Podrid PJ editors. Atrial fibrillation. mechanisms and management. New York: Raven Press, 1992: 25
Coplen SE, Antman EM, Berlin JA, et al. Efficacy and safety of quinidine therapy for maintenance of sinus rhythm after cardioversion. A meta-analysis of randomized control trials. Circulation 1990; 82: 1106–16
Pietersen AH, Hellemann H. Usefulness of flecainide for prevention of paroxysmal atrial fibrillation and flutter. Danish-Norwegian flecainide multicenter study group. Am J Cardiol 1991; 67: 713–7
Härtel G, Louhija A, Konttinen A, et al. Disopyramide in the prevention of recurrence of atrial fibrillation after electroconversion. Clin Pharmacol Ther 1974; 15:551–5
Karlson BW, Torstensson I, Abjorn C, et al. Disopyramide in the maintenance of sinus rhythm after electroversion of atrial fibrillation — a placebo controlled one year follow-up study. Eur Heart J 1988; 9: 284–90
UK Propafenone PSVT Study Group. A randomized, placebo-controlled trial of propafenone in the prophylaxis of paroxysmal supraventricular tachycardia and paroxysmal atrial fibrillation. Circulation 1995; 92: 2550–7
Anderson JL, Gilbert EM, Alpert BL, et al. Prevention of symptomatic recurrences of paroxysmal atrial fibrillation in patients initially tolerating antiarrhythmic therapy: a multicenter, double-blind, crossover study of flecainide and placebo with transtelephonic monitoring. Circulation 1989; 80: 1557–70
Pritchett ELC, McCarthy EA, Wilkinson WE. Propafenone treatment of symptomatic paroxysmal supraventricular arrhythmias: a randomized placebo-controlled crossover trial in patients tolerating oral therapy. Ann Intern Med 1991; 114: 539–44
Torp-Pedersen T, Moeller M, Bloch-Thomsen PE, et al. Dofetilide in patients with congestive heart failure and left ventricular dysfunction. N Engl J Med 1999; 341: 857–65
Greenbaum RA, Campbell TJ, Channer KS, et al. Conversion of atrial fibrillation and maintenance of sinus rhythm by dofetilide. The EMERALD (European and Australian multicenter evaluative research on atrial fibrillation Dofetilide) study [abstract]. Circulation 1998; Suppl. 1: 633
Pritchett ELC, Page RL, Connolly SJ, et al. ASAP Investigators: azimilide treatment of atrial fibrillation. Circulation 1998; 98 Suppl. 1–633
Flaker GC, Blackshear JL, McBride R, et al. Antiarrhythmic drug therapy and cardiac mortality in atrial fibrillation. J Am Coll Cardiol 1992; 20: 527–32
Falk RH. Proarrhythmia in patients treated for atrial fibrillation or flutter. Ann Intern Med 1992; 117: 141–50
Stevenson WG, Stevenson LW, Middlekauf HR, et al. Improving survival for patients with atrial fibrillation and advanced heart failure. J Am Coll Cardiol 1996; 28: 1458–63
The Atrial Fibrillation Investigation with Bidisomide (AFIB) Investigators: Treatment of atrial fibrillation and paroxysmal supraventricular tachycardia with bidisomide. Circulation 1997; 96: 2625–32
Nattel S. Newer developments in the management of atrial fibrillation. Am Heart J 1995; 130: 1094–106
CIBIS Investigators and Committees. The Cardiac Insufficiency Bisoprolol Study II (CIBIS-II): a randomised trial. Lancet 1999; 353: 9–13
MERIT-HF Investigator Group. Effect of metoprolol CR XL in chronic heart failure: Metoprolol CR XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF). Lancet 1999; 353: 2001–7
Olsson G, Wikstrand J, Warnold I, et al. Metoprolol-induced reduction in postinfarction mortality: pooled results from five double-blind randomized trials. Eur Heart J 1992; 13: 28–32
Olsson G, Tuomilehto J, Berglund G, et al. Primary prevention of sudden cardiovascular death in hypertensive patients. Mortality results from the MAPHY study. Am J Hypertens 1991; 4: 151–8
Gottlieb SS, McCarter RJ, Vogel RA. Effect of beta-blockade on mortality among high-risk and low-risk patients after myocardial infarction. N Engl J Med 1998; 339: 489–97
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Kühlkamp, V., Bosch, R., Mewis, C. et al. Use of β-Blockers in Atrial Fibrillation. Am J Cardiovasc Drugs 2, 37–42 (2002). https://doi.org/10.2165/00129784-200202010-00005
Published:
Issue Date:
DOI: https://doi.org/10.2165/00129784-200202010-00005