Dawaa Reference

chronic

Atrial Fibrillation (Rate Control & Primary Care Referral)

Treatment options, dosing, cautions and Egyptian brands from the shipped Dawaa Reference card.

Evidence status

Checked against the sources named below

Sources4 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 against4 documents
  • 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)

Verified date2026-08

Presentation reference

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

Scores

  • CHA2DS2-VASc — Does this atrial fibrillation need anticoagulation?
  • ORBIT bleeding risk — How high is the bleeding risk on anticoagulation?

SourceStatPearls "Atrial Fibrillation" - disease-level clinical article

Presentation findings are traced to the source above.

Rx: Rate control | Stroke prevention | Main treatment

RATE CONTROL - choose one

1

BISOPROLOL

Rate control

1st line

Strength5 mg

Formoral.solid

Adult dose and duration

1.25-20 mg once daily for rate control (target resting HR <110 bpm) - long-term

Paediatric dose

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.

Dose 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.

Cautions
  • 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.
Egyptian brands
Egyptian brandManufacturerIndicative price
BISOPROL 5 MG 20 F.C. TAB.BIOPHARM EGYPT9.00 EGP (0.45/unit)
CAPROL 5MG 30 F.C.TAB.INTERNATIONAL DRUG AGENCY (IDI) > NOVELL PHARMA18.00 EGP (0.60/unit)
BISOBETA 5MG 20 F.C. TAB.MEMPHIS14.00 EGP (0.70/unit)
SOPROL 5MG 20 F.C.TAB.EVA PHARMA14.00 EGP (0.70/unit)
NORMOCARD 5 MG 30 TAB.PHARMA CURE54.00 EGP (1.80/unit)
BISOLOCK 5 MG 30 F.C.TABS.PHARCO57.00 EGP (1.90/unit)
EGYPRO 5 MG 30 TAB.EGPI > ABBOTT63.00 EGP (2.10/unit)
CONCOR 5 MG 30 F.C. TABS.AMOUN > MERCK KGAA F.R.GERMANY72.00 EGP (2.40/unit)
2

METOPROLOL SUCCINATE

Rate control

1st line

Strength50 mg

Formoral.solid

Adult dose and duration

47.5-95 mg once daily (modified-release), titrate to max 190 mg once daily - long-term

Paediatric dose

Specialist pediatric cardiology management

Dose 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.

Cautions
  • 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.
Egyptian brands
Egyptian brandManufacturerIndicative price
SELOKENZOC 50 MG 28 PROLONGED R.TABS.ASTRA ZENECA94.00 EGP

STROKE PREVENTION

3

APIXABAN

Stroke prevention

1st line

Strength5 mg

Formoral.solid

Adult dose and duration

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

Paediatric dose

Safety and effectiveness have not been established in children. Atrial fibrillation in a child is a paediatric cardiology problem.

Dose 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.

Cautions
  • 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.
Egyptian brands
Egyptian brandManufacturerIndicative price
ENDLIXABAN 5 MG 30 F.C. TABS.ATCO PHARMA268.50 EGP (8.95/unit)
PIXCOLT 5 MG 30 F.C.TABS.MINA PHARM268.50 EGP (8.95/unit)
PREVAXINAL 5 MG 30 F.C. TABS.DBK PHARMA268.50 EGP (8.95/unit)
APIXAGUARD 5 MG 30 F.C. TABS.MARCYRL PHARMACEUTICAL INDUSTRIES (MPI)316.50 EGP (10.55/unit)
IKSARONT 5 MG 30 F.C. TABS.MULTI-APEX357.00 EGP (11.90/unit)
ARTIXIBAN 5 MG 30 F.C. TABS.MASH PREMIERE444.00 EGP (14.80/unit)
STRAKOPINA 5 MG 30 F.C.TABS.GLOBAL NAPI PHARMACEUTICALS > GLOBAL ADVANCED PHARMACEUTICAL (GAP)444.00 EGP (14.80/unit)
ELIQUIS 5 MG 20 F.C.TABS.BRISTOL-MYERS SQUIBB > UNITED COMPANY FOR DISTRIBUTION532.00 EGP (26.60/unit)

MAIN TREATMENT - choose one

4

REFERRAL & SAFETY-NETTING (NO DRUG THERAPY)

1st line
Dose 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.

Cautions
  • RED FLAG - Hemodynamic instability requires immediate emergency cardioversion.
5

DILTIAZEM

2nd line

Strength60 mg

Formoral.solid

Adult dose and duration

60 mg three times daily up to 360 mg modified-release once daily - long-term

Paediatric dose

Specialist use only

Dose 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.

Cautions
  • 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.
Egyptian brands
Egyptian brandManufacturerIndicative price
DILTIAZEM 60MG 20 TAB.EIPICO19.00 EGP (0.95/unit)
ALTIAZEM 60 MG 40 M.R. TABS.EIPICO > LUSOFARMACO-ITALY68.00 EGP

Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy.