E. Bisoprolol – Explanation

Atrial fibrillation: rate control – beta blockers preferable to digoxin

This question reiterates an important point which frequently comes up in exams – digoxin is no
longer first-line for rate control in atrial fibrillation. Her shortness-of-breath is likely to be rate related
and does not necessarily mean that she is in heart failure. This is supported by a normal chest x-ray.
Please see the NICE guidelines for further information.
Atrial fibrillation: rate control and maintenance of sinus rhythm

The Royal College of Physicians and NICE published guidelines on the management of atrial
fibrillation (AF) in 2006. The following is also based on the joint American Heart Association (AHA),
American College of Cardiology (ACC) and European Society of Cardiology (ESC) 2012 guidelines

Agents used to control rate in patients with atrial fibrillation

• beta-blockers
• calcium channel blockers
• digoxin (not considered first-line anymore as they are less effective at controlling the heart rate
  during exercise. However, they are the preferred choice if the patient has coexistent heart failure)

Agents used to maintain sinus rhythm in patients with a history of atrial fibrillation

• sotalol
• amiodarone
• flecainide
• others (less commonly used in UK): disopyramide, dofetilide, procainamide, propafenone, quinidine

The table below indicates some of the factors which may be considered when considering either a
rate control or rhythm control strategy