From the Guidelines
Oral treatment options for rate control in atrial fibrillation (AFib) primarily include beta-blockers, calcium channel blockers, and digoxin, with beta-blockers, diltiazem, verapamil, or digoxin recommended as first-choice drugs in patients with AF and LVEF >40%. The choice of medication depends on the patient's left ventricular ejection fraction (LVEF), with beta-blockers and/or digoxin recommended in patients with AF and LVEF ≤40% 1. Key medications for rate control include:
- Beta-blockers such as metoprolol, atenolol, or bisoprolol, which are effective at reducing heart rate both at rest and during exercise
- Non-dihydropyridine calcium channel blockers like diltiazem or verapamil, which are effective first-line agents, particularly in patients with contraindications to beta-blockers
- Digoxin, which can be used as an adjunct therapy or in sedentary patients, though it's less effective during exercise or stress 1. For patients with inadequate rate control on a single agent, combination therapy may be necessary, with the target heart rate typically less than 80 beats per minute at rest and less than 110 beats per minute during moderate exercise. Regular monitoring of heart rate, blood pressure, and potential side effects is essential, with dose adjustments made accordingly, and patients with renal impairment may require dose adjustments, particularly for digoxin 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. Although a risk of this occurring with oral verapamil has not been established, such patients receiving oral verapamil may be at risk and its use in these patients is contraindicated (see CONTRAINDICATIONS).
The oral treatment options for rate control in atrial fibrillation (AFib) include:
- Digoxin: used for control of ventricular rate in patients with atrial fibrillation, with doses titrated to the minimum that achieves the desired ventricular rate control without causing undesirable side effects 2
- Verapamil: may be used for rate control in AFib, but its use is contraindicated in patients with accessory bypass tract (Wolff-Parkinson-White or Lown-Ganong-Levine) 3
From the Research
Oral Treatment Options for Rate Control in Atrial Fibrillation (AFib)
The following oral treatment options are available for rate control in AFib:
- Beta-blockers: effective in controlling the ventricular rate at rest and during exercise 4
- Rate limiting calcium antagonists: recommended as first line treatment by the National Institute for Health and Clinical Excellence (NICE) and the American College of Cardiology/American Heart Association/European Society of Cardiology (ACC/AHA/ESC) 5
- Digoxin: can be used in combination with beta-blockers or calcium antagonists for rate control in chronic atrial fibrillation 5
- Non-dihydropyridine calcium channel blockers: can be used for rate control in patients with AFib 6
Comparison of Oral Treatment Options
Studies have compared the efficacy of different oral treatment options for rate control in AFib:
- A study comparing four single-drug regimens found that diltiazem 360 mg/day was the most effective in reducing the heart rate in patients with permanent AFib 7
- Beta-blockers, such as metoprolol, can be effective in maintaining sinus rhythm and controlling the ventricular rate during AFib 4
- The combination of digoxin with either a beta-blocker or calcium antagonist may be considered as first line management in patients with chronic atrial fibrillation 5
Guidelines and Recommendations
Guidelines and recommendations for rate control in AFib include: