# Atrial Fibrillation (Rate Control & Primary Care Referral) - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: ESC Guidelines for the management of atrial fibrillation 2020 · ESC Guidelines for the management of atrial fibrillation 2020 Table 11 · Egyptian National Drug Formulary - Blood Disorders 2025 (apixaban monograph) · Egyptian National Drug Formulary, cardiovascular 2025, metoprolol monograph (printed p. 120) - Verified date: 2026-08 ## Verified against - ESC Guidelines for the management of atrial fibrillation 2020 Table 11 - Egyptian National Drug Formulary - Blood Disorders 2025 (apixaban monograph) - Egyptian National Drug Formulary, cardiovascular 2025, metoprolol monograph (printed p. 120) - Atrial Fibrillation - disease-level clinical article (atrial-fibrillation-referral-clinical.txt) ## Treatment metadata - Bisoprolol — 5 mg — oral.solid - Metoprolol succinate — 50 mg — oral.solid - Apixaban — 5 mg — oral.solid - Referral & safety-netting (no drug therapy) - Diltiazem — 60 mg — oral.solid ## Complete treatment card ```text ATRIAL FIBRILLATION (RATE CONTROL & PRIMARY CARE REFERRAL) Sources: ESC Guidelines for the management of atrial fibrillation 2020 · ESC Guidelines for the management of atrial fibrillation 2020 Table 11 · Egyptian National Drug Formulary - Blood Disorders 2025 (apixaban monograph) · Egyptian National Drug Formulary, cardiovascular 2025, metoprolol monograph (printed p. 120) Review status: REVIEWED against ESC Guidelines for the management of atrial fibrillation 2020 Table 11, Egyptian National Drug Formulary - Blood Disorders 2025 (apixaban monograph), Egyptian National Drug Formulary, cardiovascular 2025, metoprolol monograph (printed p. 120), Atrial Fibrillation - disease-level clinical article (atrial-fibrillation- referral-clinical.txt) (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (8) - It runs from no symptoms at all to cardiogenic shock or a stroke, so a quiet patient is not a reassuring one - Ask about palpitations, chest pain, breathlessness, swelling of the legs, breathlessness on effort and dizziness [breathlessness · chest pain · dizziness · leg swelling · palpitations] - Ask how long it has been going on, how often, what sets it off, and what stopped it last time - Take a drug history for anti-arrhythmics, and a history of any previous heart disease - The risk factors to hunt for: high blood pressure, valve or ischaemic heart disease, sleep apnoea and obesity [apnoea · hypertension · ischaemia · obesity] - Also smoking, alcohol, illicit drugs, past rheumatic fever, past pericarditis and a high cholesterol [fever] - It runs from nothing at all to chest pain, palpitations, a racing heart, breathlessness, nausea, dizziness, heavy sweating and flat exhaustion [breathlessness · chest pain · dizziness · fatigue · nausea · palpitations · sweating] - It is a fast arrhythmia, so the rate is usually high, and it is called paroxysmal under seven days and persistent beyond that [arrhythmia] SIGNS - what you find (8) - The first question at the bedside is whether the patient is haemodynamically stable, before anything else - The pulse is fast and irregular in a way that has no pattern to it, usually between 110 and 140 - Check the legs for swelling, feel the pulses in all four limbs, and look for hair loss or broken skin [hair loss] - The neck may give away carotid disease or a thyroid problem, which is where the cause often is - Crackles in the chest suggest heart failure; wheeze suggests the lungs were already diseased [crackles · wheeze] - Listen at all four areas and feel the apex beat - a valve lesion is a common driver - A big liver or a distended abdomen also points to heart failure; palpate the aorta while you are there [abdominal distension] - Examine the nervous system - it may show that a stroke or a TIA has already happened TESTS (7) - The ECG makes the diagnosis: a narrow complex rhythm with no order to it and no visible P waves - Fibrillatory waves may or may not be there, and the ventricular rate usually falls between 80 and 180 - Bloods look for the cause: a blood count for infection, electrolytes, and thyroid function for an overactive gland - A chest film, plus cardiac markers and BNP to expose heart disease underneath - Consider a clot on the lung as the cause - strain on the right heart can throw the atrium into fibrillation - Score that risk with the PERC or Wells criteria rather than by impression - A swallowed echo looks for clot in the atrium, and must be done before any cardioversion to avoid causing a stroke IF NOT THIS - what else fits (4) - Atrial flutter - its irregularity has a pattern to it, where fibrillation has none - Atrial tachycardia, and its multifocal form - Wolff-Parkinson-White syndrome, where the wrong drug can be fatal - Re-entry tachycardia at the atrioventricular node Score CHA2DS2-VASc - Does this atrial fibrillation need anticoagulation? Score ORBIT bleeding risk - How high is the bleeding risk on anticoagulation? Source StatPearls "Atrial Fibrillation" - disease-level clinical article Status traced to the source above Rx: Rate control | Stroke prevention | Main treatment RATE CONTROL - choose one 1. BISOPROLOL [1st line] Adult 1.25-20 mg once daily for rate control (target resting HR <110 bpm) - long-term Peds Specialist pediatric cardiology management Choice Alternatives for rate control, once the anticoagulant is split off onto its own line. Bisoprolol is stocked by 8 products from 9 EGP; metoprolol succinate by a single product at 94. Source ESC Guidelines for the management of atrial fibrillation 2020 Table 11 Why Cardioselective beta blocker that slows conduction through the AV node, controlling the ventricular rate in atrial fibrillation; it does not restore sinus rhythm and does not settle the separate question of anticoagulation. Caution Contraindicated in severe asthma and second/third-degree AV block. Assess stroke risk using CHA2DS2-VASc score to decide anticoagulation necessity. Monitor heart rate and blood pressure. Egypt BISOPROL 5 MG 20 F.C. TAB. BIOPHARM EGYPT 9.00 EGP (0.45/unit) CAPROL 5MG 30 F.C.TAB. INTERNATIONAL... 18.00 EGP (0.60/unit) BISOBETA 5MG 20 F.C. TAB. MEMPHIS 14.00 EGP (0.70/unit) SOPROL 5MG 20 F.C.TAB. EVA PHARMA 14.00 EGP (0.70/unit) NORMOCARD 5 MG 30 TAB. PHARMA CURE 54.00 EGP (1.80/unit) BISOLOCK 5 MG 30 F.C.TABS. PHARCO 57.00 EGP (1.90/unit) EGYPRO 5 MG 30 TAB. EGPI > ABBOTT 63.00 EGP (2.10/unit) CONCOR 5 MG 30 F.C. TABS. AMOUN > MERCK... 72.00 EGP (2.40/unit) 2. METOPROLOL SUCCINATE [1st line] Adult 47.5-95 mg once daily (modified-release), titrate to max 190 mg once daily - long-term Peds Specialist pediatric cardiology management Source Egyptian National Drug Formulary, cardiovascular 2025, metoprolol monograph (printed p. 120) Why Cardioselective beta blocker used as an alternative to bisoprolol for AV-nodal rate control in atrial fibrillation, chosen when a modified-release formulation is preferred. Caution CONTRAINDICATED in asthma/severe bronchospasm, second- or third-degree AV block, severe sinus bradycardia, and cardiogenic shock. Assess stroke risk using CHA2DS2-VASc score to determine indication for oral anticoagulation. Avoid abrupt withdrawal to prevent rebound tachycardia and myocardial ischemia; monitor heart rate and blood pressure. The formulary's ceiling is higher than the dose given here - up to 400 mg daily, stepped up weekly - but rate control in atrial fibrillation rarely needs to go near it. Egypt SELOKENZOC 50 MG 28 PROLONGED R.TABS. ASTRA ZENECA 94.00 EGP STROKE PREVENTION 3. APIXABAN [1st line] Adult 5 mg twice daily. Reduce to 2.5 mg twice daily if at least two of: age 80 or over, body weight 60 kg or less, serum creatinine 1.5 mg/dL or higher. Also 2.5 mg twice daily if creatinine clearance is 15-29 mL/min - Long-term, for as long as the atrial fibrillation and the stroke risk persist Peds Safety and effectiveness have not been established in children. Atrial fibrillation in a child is a paediatric cardiology problem. Source Egyptian National Drug Formulary - Blood Disorders 2025 (apixaban monograph) Why This is the biggest clinical gap the orphan list exposed. The condition currently lists three rate-control drugs and no anticoagulant, yet stroke prevention is what changes outcome in atrial fibrillation. 28 live Egyptian products. Caution This is stroke prevention, not rate control - decide with CHA2DS2-VASc and assess bleeding risk with HAS-BLED before starting. Contraindicated in active pathological bleeding, in liver disease with coagulopathy, and with ANY other anticoagulant. Contraindicated where there is recent GI ulceration, oesophageal varices, recent intracranial or spinal surgery or haemorrhage, or a vascular aneurysm. Not for a mechanical heart valve or moderate-to-severe mitral stenosis - those need warfarin. No INR monitoring is needed, but check renal function, haemoglobin and weight at least annually so the reduced dose criteria are applied when they arise. Do not add to dual antiplatelet therapy without cardiology advice. Check adherence at every visit - a missed twice-daily dose leaves the patient unprotected within a day. Egypt ENDLIXABAN 5 MG 30 F.C. TABS. ATCO PHARMA 268.50 EGP (8.95/unit) PIXCOLT 5 MG 30 F.C.TABS. MINA PHARM 268.50 EGP (8.95/unit) PREVAXINAL 5 MG 30 F.C. TABS. DBK PHARMA 268.50 EGP (8.95/unit) APIXAGUARD 5 MG 30 F.C. TABS. MARCYRL PHARM... 316.50 EGP (10.55/unit) IKSARONT 5 MG 30 F.C. TABS. MULTI-APEX 357.00 EGP (11.90/unit) ARTIXIBAN 5 MG 30 F.C. TABS. MASH PREMIERE 444.00 EGP (14.80/unit) STRAKOPINA 5 MG 30 F.C.TABS. GLOBAL NAPI P... 444.00 EGP (14.80/unit) ELIQUIS 5 MG 20 F.C.TABS. BRISTOL-MYERS... 532.00 EGP (26.60/unit) MAIN TREATMENT - choose one 4. REFERRAL & SAFETY-NETTING (NO DRUG THERAPY) [1st line] Adult Source Atrial Fibrillation - disease-level clinical article (atrial-fibrillation-referral- clinical.txt) Why Carries the referral criteria and warning signs for this condition, which apply whichever treatment is chosen. Caution RED FLAG - Hemodynamic instability requires immediate emergency cardioversion. 5. DILTIAZEM [2nd line] Adult 60 mg three times daily up to 360 mg modified-release once daily - long-term Peds Specialist use only Source ESC Guidelines for the management of atrial fibrillation 2020 Table 11 Why Non-dihydropyridine calcium channel blocker that slows AV-nodal conduction, used as a second-line rate-control option for atrial fibrillation when a beta blocker is contraindicated or not tolerated; avoided in heart failure with reduced ejection fraction because of its negative effect on contractility. Caution CONTRAINDICATED in heart failure with reduced ejection fraction (HFrEF, LVEF <40%), second- or third-degree AV block, and sick sinus syndrome. Assess stroke risk using CHA2DS2-VASc score to decide oral anticoagulation necessity. Potent CYP3A4 inhibitor; check for significant drug interactions with statins, DOACs, and digoxin. Egypt DILTIAZEM 60MG 20 TAB. EIPICO 19.00 EGP (0.95/unit) ALTIAZEM 60 MG 40 M.R. TABS. EIPICO > LUSO... 68.00 EGP Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)