Treatment Strategies for Rate and Rhythm Control in Atrial Fibrillation
Rate control should be the initial approach for most patients with atrial fibrillation, especially elderly patients with minor symptoms (EHRA score 1), while rhythm control is recommended for patients who remain symptomatic despite adequate rate control. 1
Initial Management Decision: Rate vs. Rhythm Control
Rate Control Strategy
- Rate control is recommended as first-line therapy for most patients with AF, particularly elderly patients with mild symptoms 2, 1
- Rate control should be continued throughout a rhythm control approach to ensure adequate ventricular rate control during AF recurrences 2, 1
- Multiple clinical trials (AFFIRM, RACE, PIAF, STAF, AF-CHF) have demonstrated that rate control is not inferior to rhythm control in terms of mortality and cardiovascular events 2, 1
Rhythm Control Strategy
- Rhythm control is recommended for patients with symptomatic (EHRA score >2) AF despite adequate rate control 2, 1
- Rhythm control should be considered for patients with AF and AF-related heart failure for symptom improvement 2
- Rhythm control as an initial approach should be considered in young symptomatic patients in whom catheter ablation treatment has not been ruled out 2
Rate Control Medications
First-Line Rate Control Agents
- For patients with LVEF >40%: Beta-blockers, non-dihydropyridine calcium channel blockers (diltiazem, verapamil), or digoxin 2, 3
- For patients with LVEF ≤40%: Beta-blockers and/or digoxin are recommended 3
- In the acute setting without pre-excitation, intravenous beta-blockers or non-dihydropyridine calcium channel blockers are recommended 2
Second-Line Rate Control Agents
- Intravenous amiodarone can be useful for rate control in critically ill patients without pre-excitation 2
- Oral amiodarone may be used for ventricular rate control when other measures are unsuccessful or contraindicated 2
- AV nodal ablation with permanent ventricular pacing is reasonable when pharmacological therapy is inadequate and rhythm control is not achievable 2
Rate Control Target
- A lenient rate control strategy (resting heart rate <110 bpm) may be reasonable when patients remain asymptomatic and LV systolic function is preserved 2, 3
- For symptomatic patients, a stricter heart rate control (resting heart rate <80 bpm) strategy is reasonable 2
Rhythm Control Approaches
Pharmacological Cardioversion
- Class I antiarrhythmic drugs (flecainide, propafenone) for patients without structural heart disease 4
- Amiodarone for patients with structural heart disease or heart failure 4
- Propafenone is indicated to prolong the time to recurrence of paroxysmal atrial fibrillation/flutter associated with disabling symptoms 5
Electrical Cardioversion
- Recommended for patients with AF or atrial flutter as a method to restore sinus rhythm when pursuing a rhythm-control strategy 2
- Indicated when rapid ventricular response to AF does not respond promptly to pharmacological therapies and contributes to ongoing myocardial ischemia, hypotension, or heart failure 2
Maintenance of Sinus Rhythm
- First-choice antiarrhythmic drugs for patients with non-structural heart disease: dronedarone, flecainide, propafenone, or sotalol 4
- For patients with abnormal ventricular function but LVEF >35%: dronedarone, sotalol, or amiodarone 4
- For patients with LVEF <35%: amiodarone is the only drug usually recommended 4
Catheter Ablation
- Consider for patients who remain symptomatic after adequate trials of antiarrhythmic drug therapy and in whom a rhythm control strategy remains desired 4, 6
Important Caveats and Contraindications
- Dronedarone should not be used to control ventricular rate in patients with permanent AF as it increases risk of adverse cardiovascular outcomes 2
- In patients with pre-excitation and AF, digoxin, non-dihydropyridine calcium channel antagonists, or amiodarone should not be administered as they may increase ventricular response and result in ventricular fibrillation 2
- Non-dihydropyridine calcium channel blockers should not be used in patients with decompensated heart failure 2
- Verapamil should be avoided in patients with severe left ventricular dysfunction (ejection fraction <30%) 7
- Propafenone should not be used to control ventricular rate during atrial fibrillation 5
- AV nodal ablation should not be performed without prior attempts to achieve rate control with medications 2