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Beta Blockers vs Calcium Channel Blockers for Atrial Fibrillation Rate Control: Thinking Beyond the EDIntravenous beta blockers and non-dihydropyridine calcium channel blockers are recommended first-line for atrial fibrillation (AF) with rapid ventricular rate (RVR) [1]. In a previous post, Bryan Hayes (@PharmERToxGuy) provided an overview of the data comparing beta blockers to calcium channel blockers for atrial fibrillation rate control in the ED. Here is part 2 of our two-part AF series.Thinking Beyond the Emergency DepartmentAlthough clinicians are cautioned regarding their use in heart failure or hypotension, minimal guidance is provided on which of the two classes is most appropriate in an individual patient. While acute rate control is certainly an important therapeutic goal for patients in AF with RVR, consideration of the patient’s comorbid conditions may be just as important for determining which drug class represents a more viable long-term solution. As a consequence, judicious selection of initial therapy may therefore avoid unnecessarily prolonging a patient’s hospitalization while therapy is transitioned. The following are several common comorbidities of AF where one agent may be more ideal over another: 1. Heart failureBoth beta blockers and non-dihydropyridine calcium channel blockers exert negative inotropic effects in the acute setting and should therefore be used with caution in patients with heart failure with reduced ejection fraction (HFrEF). However, long-term beta blocker use confers significant improvements in survival whereas non-dihydropyridine calcium channel blockers either exert no beneficial effects or may even worsen outcomes [2-4]. For these reasons, the use of non-dihydropyridine calcium channel blockers should generally be avoided in patients with HFrEF despite minimal differences in their acute risks [5]. 2. Ischemic heart diseaseAlthough both classes are associated with improvements in major adverse cardiovascular events in patients with a history of myocardial infarction (MI), only beta blockers have been associated with reductions in the incidence of ventricular arrhythmias and sudden cardiac death [3, 4, 6]. Notably the benefits of beta blockers in the post-MI setting appear to attenuate over time, though they remain a standard of care and should be favored over non-dihydropyridine calcium channel blockers. The latter remain an option in patients with chronic stable angina or those whose symptoms are refractory to maximally-tolerated doses of beta blockers. 3. HypertensionAlong with angiotensin-converting enzyme inhibitors (ACEi), angiotensin II receptor blockers (ARB), and thiazide diuretics, calcium channel blockers are recommended as a first-line option for patients with high blood pressure [7]. Their use as initial therapy is especially advocated in black patients (although thiazides are a viable alternative), given improvements in long-term cardiovascular events compared to inhibitors of the renin-angiotensin-aldosterone system [8]. Beta blockers should be reserved for patients whose blood pressure remains uncontrolled despite use of the four preferred drug classes (ACEi or ARB, thiazide, or calcium channel blocker) given evidence from trials that they are less effective at preventing cardiovascular events [7]. Therefore, in patients with concomitant high blood pressure who may benefit from additional blood pressure lowering, calcium channel blockers may be a more ideal option for rate control. The addition of a nondihydropyridine calcium channel blocker should generally be avoided in patients who are already receiving a dihydropyridine calcium channel blocker (e.g., amlodipine, nifedipine), as only a minimal incremental impact on blood pressure is observed. 4. Pulmonary diseaseCalcium channel blockers should be favored over beta blockers in patients with asthma (or other forms of pulmonary disease with a bronchospastic component) given the risk of exacerbating bronchospasm. However, beta blockers need not be avoided in patients with chronic obstructive pulmonary disease (COPD) given lack of evidence to indicate harm and a potential benefit [9, 10]. 5. OthersClinicians may be cautioned against using beta blockers in a number of other disease states, including diabetes mellitus, peripheral vascular disease, depression, and erectile dysfunction. However, in each case minimal evidence supports the risk of exacerbating disease and in most cases the benefits of therapy outweigh risks. That being said, a calcium channel blocker would be an acceptable choice in any of these conditions in the absence of compelling indications for beta blocker therapy. Bottom lineBoth beta blockers and calcium channel blockers appear safe and effective for acute rate control in AF with RVR. However, given the compelling benefits of one class over the other in several common comorbidities, initial selection should take these factors into consideration so that the medication chosen can represent both a short- and long-term solution. References
Edited by Bryan D. Hayes, PharmD, FAACT Related PostsPage load linkWhy use a calcium channel blocker instead of a beta blocker?Calcium channel blockers should be favored over beta blockers in patients with asthma (or other forms of pulmonary disease with a bronchospastic component) given the risk of exacerbating bronchospasm.
What is the drug of choice for atrial fibrillation?Beta blockers and calcium channel blockers are the drugs of choice because they provide rapid rate control. These drugs are effective in reducing the heart rate at rest and during exercise in patients with atrial fibrillation.
Which is better betaSince calcium channel blockers may harm a subgroup of hard-to-identify patients and are not more effective than beta blockers, beta blockers remain the choice of the MDPB for rate control.
Do calcium channel blockers treat AFib?Calcium channel blockers are one type. They treat AFib by slowing your heart rate and relaxing the heart muscle so it doesn't have to work as hard.
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