Are beta blockers recommended in vagally mediated atrial fibrillation in the US? The Euro Heart Study indicated that 19 percent of vagal afib patients treated with “non recommended treatment” (beta blockers) developed persistent or permanent Afib after one year, as opposed to zero in the group recieving recommended treatment (anti arrhythmics). However, the 2014 AHA/ACC/HRS guidelines for management of Afib says the avoidance of beta blockers for vagally mediated Afib is an unproven hypothesis.
I was recently diagnosed with vagal Afib and prescribed metoprolol, and am concerned about turning my one episode of Afib into a permanent condition. Do you have any suggestions or sources to reference when speaking with my doctor? Thanks for your time and all the great content on the site!
Hi there,
Thanks for the question. This is unfortunately a topic that remains relatively poorly understood (and somewhat difficult to define in practice as well), and is probably a better question for a cardiac electrophysiologist than for me. You are correct that the beta blocker hypothesis remains in the “theoretical” category.
From this 2015 paper: Vagal atrial fibrillation: What is it and should we treat it? - PubMed
The 2014 AHA/ACC/ESC guidelines for management of AF [111] spe- cifically discuss the pharmacological management of vagally-induced AF. They recommend as first line, use of disopyramide — a long acting anti-cholinergic agent. They mention that beta-blockers, theoretically, could aggravate vagally-mediated AF. The previous 2006 guidelines[112] expanded further, suggesting flecainide and amiodarone as other suitable options and discouraging not only beta-blockers but sotalol, digoxin and propafenone as potentially worsening vagal AF due to intrinsic anti-adrenergic activity. Interestingly, work using the Euro Heart Survey has found that 72% of patients identified as having vagal AF received medication which was different to that recommended by the AHA/ACC/ESC guidelines [49], with, perhaps surprisingly, similar use of beta-blockers in patients with and without vagal triggers. As mentioned earlier, those treated in accordance with guidelines faired significantly better in terms of progression but not symptom burden.
Thank you for the information, I appreciate it.