Rate Control in Atrial Fibrillation

First-Line Agents

• The American College of Cardiology recommends beta blockers or nondihydropyridine calcium channel antagonists as first-line agents for rate control in patients with atrial fibrillation, with a preference for beta blockers in patients with heart failure with reduced ejection fraction (HFrEF) 1, 2, 3
• For patients with atrial fibrillation during exercise, the American College of Cardiology suggests assessing the adequacy of heart rate control during activity and adjusting medication to maintain a physiological heart rate range 2
• In patients with atrial fibrillation and heart failure with preserved ejection fraction (HFpEF), either beta blockers or nondihydropyridine calcium channel antagonists are considered appropriate first-line agents 4

Second-Line and Combination Therapy

• Digoxin is effective for rate control at rest but should be used as a second-line agent, and is appropriate for patients with heart failure, left ventricular dysfunction, or sedentary individuals, according to the American College of Cardiology 1, 2
• A combination of digoxin with either a beta blocker or nondihydropyridine calcium channel antagonist is reasonable to control heart rate both at rest and during exercise, as recommended by the American College of Cardiology 1, 2, 4

Special Considerations

• In patients with atrial fibrillation and acute heart failure or hemodynamic compromise, the American Heart Association recommends intravenous digoxin or amiodarone for acute rate control 3, 4
• Oral amiodarone may be considered when ventricular rate cannot be adequately controlled with beta blockers, calcium channel antagonists, or digoxin, alone or in combination, according to the American College of Cardiology 1, 2

Heart Rate Targets

• Lenient rate control (resting heart rate <110 bpm) is an acceptable initial approach for most patients with atrial fibrillation, unless symptoms call for stricter control, as suggested by the European Society of Cardiology 6, 7
• The RACE II study showed no difference in clinical outcomes between strict and lenient rate control strategies in patients with atrial fibrillation, according to the European Heart Journal 6, 7

Invasive Approaches

• When pharmacological therapy is insufficient or associated with side effects, catheter ablation of the AV node with pacemaker implantation can be considered for patients with atrial fibrillation, as recommended by the American College of Cardiology 1, 2
• AV node ablation should not be attempted without a prior trial of medication to control ventricular rate, according to the American College of Cardiology 2

Potential Pitfalls and Caveats

• Digitalis should not be used as the sole agent for rate control in patients with paroxysmal atrial fibrillation, as recommended by the American College of Cardiology 2
• Nondihydropyridine calcium channel antagonists should be avoided in patients with decompensated heart failure as they may worsen hemodynamic compromise, according to the American College of Cardiology 8