From the Guidelines
All patients with atrial fibrillation (AF) should be initially managed with rate control, as it is recommended as the initial therapy in the acute setting, an adjunct to rhythm control therapies, or as a sole treatment strategy to control heart rate and reduce symptoms. This approach is supported by the 2024 ESC guidelines for the management of atrial fibrillation, which suggest that rate control therapy is recommended in patients with AF, using medications such as beta-blockers, diltiazem, verapamil, or digoxin as first-choice drugs in patients with AF and LVEF >40% to control heart rate and reduce symptoms 1.
Key Considerations
- The decision between rate and rhythm control should consider factors such as symptom burden, age, comorbidities, and patient preference.
- Rhythm control is more appropriate for younger patients, those with symptomatic AF, recent-onset AF, or AF secondary to correctable causes.
- All AF patients should receive appropriate anticoagulation based on their CHA₂DS₂-VASc score regardless of the control strategy chosen.
- Atrioventricular node ablation combined with cardiac resynchronization therapy should be considered in severely symptomatic patients with permanent AF and at least one hospitalization for HF to reduce symptoms, physical limitations, recurrent HF hospitalization, and mortality 1.
Treatment Options
- Beta-blockers, such as metoprolol, can be used to control heart rate and reduce symptoms.
- Calcium channel blockers, such as diltiazem, can also be used to control heart rate and reduce symptoms.
- Digoxin can be used as a second-line agent for rate control in atrial fibrillation.
- Antiarrhythmic drugs, such as amiodarone, flecainide, propafenone, or sotalol, can be used for rhythm control in suitable candidates.
Recent Guidelines
The 2024 ESC guidelines for the management of atrial fibrillation provide the most up-to-date recommendations for the management of AF, and should be followed in clinical practice 1. The older guidelines, such as the 2003 American Academy of Family Physicians and the American College of Physicians guideline, are no longer the most relevant or current 1.
From the Research
Rate Control in Atrial Fibrillation
- Rate control is a widely used treatment strategy for managing patients with atrial fibrillation (AF) 2.
- Multiple studies have shown that pharmacologic rate control is as effective as pharmacologic rhythm control for management of AF 2, 3.
- The goals of rate-control therapy are to reduce symptoms, improve quality of life, minimize the development of heart failure, and prevent thromboembolic complications 4.
Assessment and Targets for Ventricular Rate
- A snapshot ECG or intermittent monitoring using Holters is the most widely used technique for assessing ventricular rate during AF 2.
- Continuous monitoring of AF and ventricular rate during AF by implantable devices is the most comprehensive method for assessment of AF occurrence and poor rate control 2.
- The ventricular rate targets for achieving good rate control during AF depend on the patient characteristics, with stricter targets recommended for patients with compromised functional capacity, such as patients with heart failure 2, 3.
- The clinical target of rate control should be a ventricular rate below 80-90 bpm at rest 3.
Treatment Options for Rate Control
- Pharmacological rate control can be achieved using digoxin, beta-blockers, calcium channel antagonists, or amiodarone 3, 5.
- Non-pharmacological approaches, such as atrioventricular node ablation coupled with pacing, can also be used for rate control 3, 4.
- The choice of rate control medication or approach should be based on clinical assessment, including the presence of underlying heart disease and hemodynamic impairment 3, 4.
Specific Considerations for Patient Subgroups
- In patients with heart failure, rate control is particularly important, and beta-blockers are preferred for stabilized heart failure, while digoxin is preferred for unstabilized forms 3, 6.
- In patients with atrial fibrillation and Wolff-Parkinson-White syndrome, beta-blockers, calcium channel blockers, and digoxin should be avoided, and procainamide or other antiarrhythmic drugs should be used instead 5.