From the Guidelines
The recommended initial treatment for rate control in atrial fibrillation is a beta-blocker, diltiazem, verapamil, or digoxin, depending on the patient's left ventricular ejection fraction (LVEF) and other clinical factors, as stated in the 2024 ESC guidelines 1. The choice of initial treatment depends on the patient's LVEF, with beta-blockers, diltiazem, verapamil, or digoxin recommended for patients with LVEF >40% 1.
- For patients with LVEF ≤40%, beta-blockers and/or digoxin are recommended 1.
- The goal of rate control is to reduce symptoms and improve quality of life, with a target heart rate of 60-100 beats per minute at rest.
- Regular monitoring of heart rate and symptoms is essential to guide dose adjustments and minimize potential side effects such as hypotension, bradycardia, and heart block.
- It is worth noting that the 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines also recommend measurement of the heart rate at rest and control of the rate using pharmacological agents, such as beta blockers or non-dihydropyridine calcium channel antagonists, for patients with persistent or permanent AF 1. However, the 2024 ESC guidelines provide more up-to-date and specific recommendations for initial treatment 1.
From the Research
Rate Control in Atrial Fibrillation
The recommended initial treatment for rate control in atrial fibrillation depends on the symptoms and clinical characteristics of the patient.
- According to 2, diltiazem 360 mg/day was the most effective drug regimen for reducing the heart rate in patients with permanent atrial fibrillation.
- The choice of rate control depends on the symptoms and clinical characteristics of the patient, but for all patients with atrial fibrillation, rate control is part of the management 3.
- Beta-blockers, alone or in combination with digoxin, or non-dihydropyridine calcium-channel blockers (not in heart failure) effectively lower the heart rate 3.
- Digoxin is least effective, but a reasonable choice for physically inactive patients aged 80 years or older, in whom other treatments are ineffective or are contraindicated, and as an additional drug to other rate-controlling drugs, especially in heart failure when instituted cautiously 3.
Treatment Options
- Beta-blockers, such as metoprolol CR/XL, may be the first line of treatment to maintain sinus rhythm, especially after myocardial infarction and in patients with chronic heart failure and in those with arterial hypertension 4.
- Calcium channel antagonists or beta-adrenoceptor antagonists (beta-blockers) are generally more appropriate and effective for patients without left ventricular dysfunction 5.
- The clinical target of rate control should be a ventricular rate below 80-90 bpm at rest 5.
- Intravenous diltiazem, metoprolol, and verapamil can be used for rate control in patients with acute atrial fibrillation with rapid ventricular rate, with no statistically significant difference between them in achieving rate control 6.
Considerations
- The choice of a rate control medication must currently be based on clinical assessment, which includes assessing the presence of underlying heart disease and haemodynamic impairment 5.
- Rate control is particularly tricky in patients with heart failure, for whom non-pharmacological options can also be considered 5.
- The preferred pharmacological options are beta-blockers for stabilised heart failure and digoxin for unstabilised forms 5.