AF with reduced ejection fraction and COPD: choosing rate control — case discussion

Presentation

Practice case (not a real patient). A 76-year-old woman with known permanent AF and COPD presents with 2 weeks of breathlessness and ankle swelling. Her ventricular rate is 124 beats per minute and her blood pressure is maintained. She is alert, has no pre-excitation on the ECG and no history of asthma or severe bronchospasm. She has been on no rate-control drug. Echocardiography shows an LVEF of 35%. With an LVEF of 35% and symptoms and signs of heart failure, she meets the ESC 2026 HF description of HFrEF: LVEF below 50% with symptoms and/or signs of HF.^[4]

Step 1 — Is she stable, and what is driving the rate?

Discussion:

• She is haemodynamically stable, so the question is drug choice; ESC 2024 recommends electrical cardioversion in AF with acute or worsening haemodynamic instability, to improve immediate patient outcomes (Class I, Level C).^[1]
• ESC 2024 says underlying causes should be evaluated and managed before, or in parallel to, acute rate control, including addressing fluid overload.^[1]
• ESC 2026 HF: diuretic therapy is indicated to relieve congestion and may increase the chances of restoring sinus rhythm by reducing filling pressures and ventricular rate.^[4]
• ESC 2024 AF text: patients presenting with new-onset or recurrent AF should be tested for thyroid-stimulating hormone (TSH) levels, and ESC 2026 HF lists hyperthyroidism among precipitating factors for AF.^[1][4]

Step 2 — Which drug first?

Discussion:

• Her LVEF of 35% puts her in the ESC 2024 group with LVEF of 40% or less, where beta-blockers and/or digoxin are recommended to control heart rate and reduce symptoms (Class I, Level B).^[1]
• ESC 2026 HF characterises HFrEF by LVEF below 50% with symptoms and/or signs of HF, and recommends beta-blockers in stable HFrEF and AF as first-line therapy for short- and long-term rate control (Class I, Level C).^[4]
• COPD does not rule out a beta-blocker: ACC/AHA 2023 says that in AF and COPD it is reasonable to use cardioselective beta blockers for rate control, especially where other indications exist (eg, MI and HF) (COR 2a, LOE B-R).^[3]
• ESC 2024 Table 12 lists bisoprolol at 1.25–20 mg once daily as the usual range for oral maintenance in rate control.^[1]
• ESC 2024 Table 12 lists beta-blockers as contraindicated in acute HF and with a history of severe bronchospasm, and ESC 2024 text calls achieving euvolaemia with diuretics an important first step that not only manages the heart failure component but can also facilitate better control of heart rate in AF; ESC 2026 HF recommends beta-blockers in stable patients, so the beta-blocker is started once her congestion is treated and she is stable.^[1][4]
• Avoid diltiazem and verapamil: ACC/AHA 2023 says nondihydropyridine calcium channel–blocking drugs should not be administered in AF with LVEF below 40%, given their potential to exacerbate HF (COR 3: Harm, LOE C-LD).^[3]

Step 3 — The rate stays high on a beta-blocker

After 4 weeks of bisoprolol at the highest dose she tolerates, and with her congestion treated, her resting rate is 116 beats per minute and she remains breathless.^[4]

Discussion:

• ESC 2026 HF: digoxin should be considered in stable patients with HFrEF and AF when the ventricular rate remains high despite beta-blockers, to obtain short- and long-term rate control (Class IIa, Level C).^[4]
• ESC 2024 Table 12 lists a usual range for oral maintenance of digoxin of 0.0625–0.25 mg once daily; check renal function before starting and adapt the dose in CKD patients.^[1]
• ACC/AHA 2023: if measuring serum digoxin levels is indicated, it is reasonable to target levels below 1.2 ng/mL (COR 2a, LOE B-NR).^[3]
• In a randomised, double-blinded, placebo-controlled study of 47 patients with persistent AF and HF (mean LVEF 24%), adding carvedilol to digoxin for four months lowered the 24-hour ventricular rate and improved LVEF and symptom score compared with digoxin alone; when patients then switched from the combination to carvedilol alone, the mean ventricular rate rose and LVEF fell.^[20]

Step 4 — What target, and when to tighten it?

Discussion:

• ESC 2026 HF: lenient rate control, with resting heart rate below 110 b.p.m., should be considered as the initial target in patients with and without HF, with re-evaluation based on symptoms.^[4]
• ESC 2024: stricter control is reserved for those with continuing AF-related symptoms (Class IIa, Level B), and ESC 2024 text names suspicion of tachycardia-induced cardiomyopathy as a reason stricter targets may be indicated.^[1]
• ACC/AHA 2023: in suspected AF-induced cardiomyopathy or refractory HF symptoms on pharmacological rate-control therapy, a stricter rate-control strategy (below 80 bpm at rest and below 110 bpm during moderate exercise) may be reasonable (COR 2b, LOE B-NR).^[3]

Step 5 — If drugs fail

Discussion:

• ESC 2026 HF: atrioventricular node ablation combined with CRT should be considered in severely symptomatic permanent AF with poor rate control despite medical therapy and at least one HF hospitalisation, to reduce symptoms, physical limitations, recurrent HF hospitalisation and death (Class IIa, Level B1).^[4]
• ACC/AHA 2023: in AF, HFrEF (LVEF below 50%) and refractory rapid ventricular response, in patients who are not candidates for or in whom rhythm control has failed, AVNA and biventricular pacing therapy can be useful to improve symptoms, QOL and EF (COR 2a, LOE B-R).^[3]
• ESC 2024 reserves amiodarone as a last option when heart rate cannot be controlled even with maximal tolerated combination therapy, or for patients who do not qualify for atrioventricular node ablation and pacing.^[1]
• ESC 2024 says dronedarone should not be instituted for rate control because it increases rates of heart failure, stroke and cardiovascular death in permanent AF.^[1]

Learning points

• In stable HFrEF with AF, ESC 2026 HF recommends beta-blockers as first-line therapy (Class I, Level C), and digoxin should be considered when the rate remains high despite beta-blockers or they are contraindicated or not tolerated (Class IIa, Level C), for short- and long-term rate control.^[4]
• Verapamil and diltiazem are contraindicated at an LVEF of 40% or less in ESC 2024 Table 12.^[1]
• ESC 2024 starts with a lenient resting target below 110 b.p.m. and reserves stricter control for continuing AF-related symptoms (Class IIa, Level B); its text adds that stricter targets may be indicated with suspected tachycardia-induced cardiomyopathy.^[1]