What are the rate control medications for atrial fibrillation (AFib)?

From the Guidelines

Beta-blockers, diltiazem, verapamil, or digoxin are recommended as first-choice drugs in patients with atrial fibrillation (AF) and left ventricular ejection fraction (LVEF) >40% to control heart rate and reduce symptoms, as stated in the 2024 ESC guidelines 1. The primary goal of rate control therapy in AF is to alleviate symptoms and improve quality of life by reducing the ventricular rate.

• Beta-blockers, such as metoprolol (25-100 mg twice daily), carvedilol (3.125-25 mg twice daily), and atenolol (25-100 mg daily), are effective first-line options for rate control in AF, as they reduce heart rate by blocking sympathetic stimulation 1.
• Non-dihydropyridine calcium channel blockers, like diltiazem (120-360 mg daily in divided doses) and verapamil (120-360 mg daily in divided doses), are also effective first-line agents that slow conduction through the AV node 1.
• Digoxin (0.125-0.25 mg daily) is typically reserved for sedentary patients or as an add-on therapy due to its slower onset and reduced efficacy during high sympathetic states 1. When selecting a medication, consider comorbidities:
• Beta-blockers are preferred in patients with coronary artery disease or heart failure with reduced ejection fraction.
• Calcium channel blockers should be avoided in heart failure patients. Combination therapy may be necessary if single-agent treatment fails to achieve adequate rate control, typically defined as a resting heart rate below 80 beats per minute and below 110 beats per minute during moderate activity 1. Regular monitoring of heart rate, blood pressure, and medication side effects is essential for optimal management. In patients with AF and LVEF ≤40%, beta-blockers and/or digoxin are recommended to control heart rate and reduce symptoms, as stated in the 2024 ESC guidelines 1.

From the FDA Drug Label

Peak digoxin body stores larger than the 8 to 12 mcg/kg required for most patients with heart failure and normal sinus rhythm have been used for control of ventricular rate in patients with atrial fibrillation Doses of digoxin used for the treatment of chronic atrial fibrillation should be titrated to the minimum dose that achieves the desired ventricular rate control without causing undesirable side effects.

Rate Control Medication for Atrial Fibrillation:

• Digoxin can be used for rate control in atrial fibrillation.
• The dose should be titrated to the minimum dose that achieves the desired ventricular rate control without causing undesirable side effects.
• Peak digoxin body stores larger than 8 to 12 mcg/kg may be used for control of ventricular rate in patients with atrial fibrillation. 2

From the Research

Rate Control Medication for Atrial Fibrillation

• The primary goal of rate control in atrial fibrillation is to reduce symptoms and prevent tachycardia-mediated cardiomyopathy 3, 4, 5.
• The choice of rate control medication depends on the symptoms and clinical characteristics of the patient, with beta blockers, digoxin, and non-dihydropyridine calcium-channel blockers being effective options 3, 6, 7.
• Beta blockers are the most potent at reducing exercise heart rate, followed by calcium channel blockers and digoxin 5.
• Digoxin is least effective but can be used as an additional drug to other rate-controlling drugs, especially in heart failure 3.
• Rate control treatment is simple and relatively easy, and should be considered initially in patients with atrial fibrillation associated with congestive heart failure 6.
• Atrioventricular node ablation with pacemaker insertion can be used as a last resort for rate control, but catheter ablation of atrial fibrillation should be considered before this approach 3, 6.

Medication Options

• Beta blockers: effective at reducing exercise heart rate and can be used as a first-line treatment 3, 6, 5, 7.
• Digoxin: can be used as an additional drug to other rate-controlling drugs, especially in heart failure, but is least effective at reducing heart rate 3, 4, 7.
• Non-dihydropyridine calcium-channel blockers: effective at reducing heart rate, but not recommended for patients with heart failure 3, 7.
• Amiodarone: can be used for both rhythm and rate control of atrial fibrillation, especially in patients with congestive heart failure 6.