What is the initial treatment for a patient with atrial fibrillation (Afib) and a controlled ventricular rate?

Initial Treatment for Atrial Fibrillation with Controlled Ventricular Rate

Beta-blockers, diltiazem, verapamil, or digoxin are recommended as first-line medications for rate control in patients with atrial fibrillation and preserved left ventricular ejection fraction (LVEF >40%). 1, 2

First-Line Medication Selection Based on Cardiac Function

For Patients with LVEF >40%:

• Beta-blockers, diltiazem, verapamil, or digoxin are recommended as first-choice drugs to control heart rate and reduce symptoms 1
• A lenient rate control approach with a resting heart rate target of <110 beats per minute should be considered as the initial goal, with stricter control reserved for patients with continuing AF-related symptoms 1

For Patients with LVEF ≤40% (Heart Failure):

• Beta-blockers and/or digoxin are recommended for rate control 1
• Avoid non-dihydropyridine calcium channel blockers (diltiazem, verapamil) in patients with decompensated heart failure as they may worsen hemodynamic status 1
• Intravenous digoxin or amiodarone is recommended to control heart rate acutely in patients with heart failure 1

Combination Therapy

• If a single drug does not adequately control symptoms or heart rate, combination rate control therapy should be considered, provided bradycardia can be avoided 1
• A combination of digoxin and a beta-blocker (or a non-dihydropyridine calcium channel antagonist for patients with preserved ejection fraction) is reasonable to control both resting and exercise heart rate 1

Special Considerations

• For patients with rapid ventricular response causing or suspected of causing tachycardia-induced cardiomyopathy, achieving rate control through either AV nodal blockade or a rhythm-control strategy is reasonable 1
• Assessment of heart rate control during exercise and adjustment of pharmacological treatment is useful in symptomatic patients during activity 1
• Atrioventricular node ablation with pacemaker implantation should be considered in patients unresponsive to or ineligible for intensive rate and rhythm control therapy 1

Acute Management

• In the absence of preexcitation, intravenous beta-blockers (esmolol, metoprolol, or propranolol) or non-dihydropyridine calcium channel antagonists (verapamil, diltiazem) are recommended to slow ventricular response in the acute setting 1
• Exercise caution with these medications in patients with hypotension or heart failure 1

Anticoagulation Considerations

• Antithrombotic therapy to prevent thromboembolism is recommended for all patients with AF, except those with lone AF or contraindications 1
• The selection of antithrombotic agent should be based on absolute risks of stroke and bleeding and the relative risk and benefit for the individual patient 1

Common Pitfalls and Caveats

• Digitalis should not be used as the sole agent to control ventricular response in patients with paroxysmal AF 1
• Catheter ablation of the AV node should not be attempted without a prior trial of medication to control ventricular rate 1
• In patients with decompensated heart failure and AF, intravenous administration of non-dihydropyridine calcium channel antagonists may exacerbate hemodynamic compromise and is not recommended 1
• Intravenous administration of digitalis glycosides or non-dihydropyridine calcium channel antagonists to patients with AF and a preexcitation syndrome may paradoxically accelerate ventricular response and is not recommended 1